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THE

DISEASES OF THE EAR.

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POLITZER'S TEXT-BOOK

DISEASES OF THE EAR

ADJACENT ORGANS.

FOR STUDENTS AND PRACTITIONERS.

TRANSLATED BY

OSCAR DODD, M.D.,

ASSISTANT-SURGBON AT THE ILLINOIS CHARITABLB BYE AND EAR INFIRMARY.
CUNICAL INSTRUCTOR OF THE IlYE AND EAR IN THE COLLBOE OF PHYSICIANS AND SURGEONS.

CHICAGO.

EDITED BY

Sre WILLIAM DALBY, F.R.C.S., M.B. Cantab ,

CONSULTING AURAL SURGEON TO ST. GEORGE'S HOSPITAL.

WITH SSO ORIGINAL ILLUSTRATIONS.

LEA BROTHERS & CO.,

PHILADELPHIA AND NEW YORK.
1894.

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BOSTON MEDICAL LIBRARY

MTHE

FRANCIS A. COUNTWAY

UBWWr OF MEDICINE rr^r^n]a

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PREFACE.

The thorough knowledge of the German and English langusiges
possessed by Dr. Dodd ensures to the English-speakmg part of the
medical profession an accurate translation of Professor Politzer's
T^xt Book.

To knowledge Dr. Dodd has added great care, so that the transla-
tion is more than accurate — ^it is excellent.

As a treatise on diseases of the ear it is complete, since it embraces
all that is known on the subject.

When questions in surgery are sub judice they are discussed in
the calm and dispassionate manner that might be expected from the
talented and well-known author. The revision of such a work, as
it has passed through the press, has been a sincere pleasure to the
editor.

W. B. DALBY.

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TO THE TRANSLATOB.

Vhnna, Jvly 21«<, 1693.
Deab Db. Dodd,

You were so kind as to take charge of the translation of
the Third Edition of my Text-book, and this work being now accom-
plished, I am anxious to express to you my full approbation of all the
particular care and conscientiousness of which you made proof in
the clear conception and reproduction of all the scientific terms in
the work.

I thank you with all my heart, and beg you will accept my fervent
congratulations for the laborious zeal with which you performed
this arduous and difficult task, as well as my sincere compliments
for the attained success.

Assuring you once more of my grateful appreciation, I am, with
kind regards.

Yours very truly,

ADAM POLITZER.

TO THE EDITOR.

Vienna, Jvly list, 1893.

Deab Sm William Dalby,

I am conscious that I am indebted to your particular
benevolence for editing Dr. Dodd's translation of the Third Edition
of my Text-book on the Diseases of the Ear.

I make no doubt that it is owing to your assistance, and your
genial and frequent inspirations, that the work has so well succeeded.

Your eminent position amongst aural Surgeons is a sure guarantee
that the work will be favourably received by our English colleagues.

Allow me, therefore, to express to you my gratification, and to thank
you most heartily for the personal interest you were so kind as to
take in the success of this work.

Let me assure you that I shall always remember your benevolent
assistance in this enterprise, and believe me, dear Sir William,

Yours most truly,

ADAM POLITZER.

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CONTENTS.

Anatomical Division of the Eab .....
The Anatoitt and Phtsiologt op the Sound-conducting Apparatus
I. The External Ear .

A. The Auricle

B. The External Meatus

a. Its Cartilaginous Portion

b. Osseous Meatus

c. The Lining Membrane of the External Meatus

d. Vessels and Nerves of the Auricle and of the External Meatus

e. Size and Direction of the External Meatus .

II. The Middlb Ear .....

A. The Tympanic Cavity ....

a. The Membrana IVmpani
6 to/. Walls of the Tympanic Cavity .
g. Ossicula .....
A. Articulation of the Ossicula .
1. Ligaments dl the Ossicula .
k. Intra-tympanio Muscles
I. Lining Membrane ....
971. Vessels and Nertee ....

B. The Eustachian Tube ....

a. The O^eous Portion of the Eustachian Tube

b. The Cartilaginous Portion of the Eustachian Tube
0. The Mastoid Process ....
D. Topography of the Sound-conducting Apparatus

Physiology op the Sound-conducting Apparatus .

A. Auricle ......

B. Conduction of Sound in the External Meatus

C. Propagation of Sound through the Membrana Tympani, and

throuflrh the Ossicula .....
a. Application of the Results to the Pathology of the Ear

D. Physiology of the Eustachian Tube

E. Application to the Pathology of the Ear

F. The Influence of the Variations of the Air-pressure in the

Tympanic Cavity upon the Tension of the Contents of the
Labyrinth .......

G. Function of the Intra-tympanic Muscles

The Methods op Physical Examination op the Organ of
Hearing .......

A. The Examination of the External Meatus and Membrana
Tympani .......

[B. Methods of Examination of the Middle Ear

The Mechanical Action of Currents of Air introduced faito the

Tympanum in the Diseases of the Middle Ear
a. Valsalvan Method .....

PAOS

2
2
8
4
5
9
10
11

18
18
14
21
27
29
31
88
85
87
39
40
41
45
51

55
55
56

57
57
68
66

66
68

70
81

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VIU CONTENTS.

PAGE

b. Catheterizatioii of the EuBtachian Tube .88

1. Topographical Relations of the Pharyngeal Orifice of

the EoBtaohian Tube . . .89

2. Choice of Catheter . . . .91

3. Method of Catheterizing the Eustachian Tube . 92
.4. Mistakes in Catheterization * . . . .97

5. Modifications of Catheterization in Cases of Congenital

or Pathological Obstacles in the Naso-Pharynx 98

6. Methods of Propelling Air into the Middle Ear by the

Catheter for Diagnostic and Therapeutic Purposes . 101
Results of Auscultation in Normal and Pathological Conditions
of the Middle Ear . . . . . lOi

7. Methods of Injection of Fluid and of the Introduction

of Vapours into the Middle Ear through the Catheter 108

c. The Author's Method of making the Eustachian Tube

Permeable. (Politzer's Method) . . . .118

The Therapeutic Value of the Author's Method (Politzerizing)

as compared with the Valsalyan Method and Catheterization 120
Methods of Examination and Treatment of the Middle Ear

through the External Meatus .... 124

a. Rarefaction of Air in the External Meatus . . .124

h. Condensation of Air in the External Mt-atus .126

C. Tests for Hearing . . . .127

A. Testing the Acuteness of the Perception of Sound-waves trans-

mitted through the Air to the Membrana Tympani . .128

1. Testing the Sharpness of Hearing for Simple Tones . 128

2. Testing the Hearing-power for Speech . . . 136

B. Testing the Perception of the Waves of Sound conducted to the

Ear through the Cranial Bones . • .141

1. Testing with the Watch and the Acoumeter . .141

2. Testing with the Tuning-fork . .148

C. Method of Examining the Patient ^ . 151

Diseases of the Sound-oonductino Apparatus . . .168

t. Diseases of the Extebnal Ear ..... 168

i. Anomalies of Secretion in the External Auditory Meatus 163

ii. Diseases of the Skin of the External Ear .... 167

A. Hypersemia of the External Ear .167

B. Inflammations of the External Ear . .168

Dermatitis of the Auticle . . . .168

B. Inflammation of the External Auditory Meatus . . .171

1. Follicular Inflammation of the External Auditory Meatus 172

2. Diffuse Inflammation of the External Auditory Meatus . 176

3. Otitis Externa Hsemorrhagica .... 180

4. Croupous and Diphtheritic Inflammation of the External

Auditory Meatus . . .181

5. Parasitic Inflammation of the External Auditory Meatus —

Mycosis of the External Meatus .183

C. Eczema of the External Ear ..... 188

D. Herpes Zoster . . . . . . .195

E. Lupus . . . . . .196

F. Syphilitic Inflammation of the External Ear . .199
•iiL Diseased of the Perichondrium and Cartilag'? of the Auricle and Ex-
ternal Meatus ....... 202

1. Othffimatoma ...... 202

2. Perichondritis of the Auricle . . 206
iv. Contractions and Adhesions of the External Auditory Meatus 207

V. Foreign Bodies in the Ear ...... 218

II. The Diseases of the Middle Ear ..... 226

A. The Diseases of the Membrana Tympani . . 226

Survey of the Histological Changes in the Membrana Tympani 227

1. Changes in the Epidermic Layer of the Membrana Timpani 227

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CONTENTS. IX

PAOB

2. Changes in the Dermic Layer of the Membrana Tympani 227

3. Changes in the Substantia Propria . 230

4. Changes in the Mucous Layer of the Membrana Tympani 281
Inflammation of the Membrana Tympani . . 232

1. Primary Acute Inflammation (Myringitis Acuta) . . 232

2. Chronic Inflammation (Myringitis Chronica) . . 288
Traumatic Lesions of the Membrana Tympani . . 241

B. The Diseases of the Cavum Tympani, the Eustachian Tube and

the Mastoid Process . . . .250

1. Catarrh of the Middle Ear . . .253

a. The Secreting form of Middle>ear Catarrh . . 254

6. The Catarrhsd Adhesive Processes in the Middle Ear 274

The Constrictions of the Eustachian Tube and their Treatment 302

The Operative Treatment of the Adhesive Processes . . 309

1. The Artificial Perforation of the Membrana Tympani . 309

2. Section of the Posterior Fold of the Membrana l^rmpani . 312

3. Tenotomy of the Musculus Tensor Tympani and M.

Stapedius . . . . .815

4. Mobilization and Extraction of the Stapes . .317

5. The Synechotomy of the Crura of the Stapes . . 321

6. The Excision of the whole Membrana Tympani and the

Extraction of the Malleus and Incus . . . 323
ii. The Muco-purulent Inflammations of the Mucous Membrane of the

Middle Ear 325

a. Acute Inflammation of the Middle Ear . . . 325

b. Acute Purulent Inflammation of the Middle Ear . 339

c. Chronic Purulent Inflammation of the Middle Ear . . 354

1. The Closure of Perforations with Cicatricial Tissue . 375

2. Adhesion between the Membrana Tympani and the

Inner Wall of the Tympanic Cavity . . .379

3. Epidermization of the Edges with persistence of Per-

forations in the Membrana Tympani . . . 387

4. The Desquamative Processes and the Formation of

Cholesteatoma in the Ear during Chronic Middle-ear

Suppuration ...... 390

The Peculiarities of Suppurative Middle-ear Inflaounation

occurring with Infectious Diseases .... 400

Purulent Middle-ear Inflammation occurring with Typhoid
Fever. . . . . . . .401

Suppurative Middle-ear Inflammation with Influenza . . 402

Scarlatino-Diphtheritic Middle-ear Suppuration . . 408

Suppurative Middle-ear Inflammation with Tuberculosis . 406

Middle-ear Suppuration following Syphilis . . . 409

Treatment of Chronic Middle- ear Suppuration . . 410
Treatment of Granular Middle-ear Suppuration . .419
Treatment of Desquamative Middle-ear Suppuration and

Cholesteatoma in the Temporal Bone . . . 421
Treatment of Cholesteatoma and Suppuration in Prussak's

Space and in the External Attic of the Tympanic Cavity . 423
Concluding Remarks on the Treatment of Chronic Middle- ear

Suppuration ....... 426

a. Treatment of the Deafness .... 428

6. The Artificial Membrana Tympani . . .429

The Operative Treatment of Chronic Suppuration of the

Middle Ear 483

a. Operations during the Suppuration . . . 433
6. Intra-tympanic Operations after Suppuration of the

Middle Ear is exhausted . . . . 485

Carious Affections of the Temporal Bone developed in the

Course of Suppuration of the Middle Ear . . . 442
The Extraction of ihe Ossicula in Chronic Middle-ear Sup-
puration ....... 460

Intra-cranial Diseases of Otitic Origin .... 466

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CONTENTS.

Sub-dural Abscess and Otitic Meningitis

1. Sub-dursJ Abscess ....

2. Otitic Meningitis ....

3. Otitic Cerebral Abscess
The Surgical Opening of Otitic Abscesses of the Brain
Sinus-Phlebitis of Otitic Origin

Operative Treatment of Thrombosis of the Transverse 8inus
Fatal Hemorrhage in consequence of Erosion of the Internal

Carotid Artery . ' .

The Diseases of the Mastoid Process ....

A. Primary Acute Inflammation of the External Mastoid Region

B. Inflammation of the Cell-spaces of the Mastoid Process

a. Primary Acute Inflammation of the Mastoid Cells .

b. Inflammation of the Mastoid Cells during the course of

Acute Middle ear Suppuration
Indications for Opening the Mastoid Process

c. The Secondary Chronic Diseases of the Mastoid Process
Operative Opening of the Mastoid Process in Chronic Middle-
ear Suppuration ......

The Chiselling away of the Posterior Superior Wall of the

Meatus and laying free the Tympanic Cavity
New-formations in the Sound -conducting Apparatus

1. Connective-tissue New-formations

a. On the Auricle
6. In the External Meatus and in the Middle Ear.
Aural Polypi
Treatment. — (1) Operative Treatment

(2) Treatment by Medicated Applica-
tions

2. Epithelial New- formations
Neuroses of the Sound-conducting Apparatus .

1. Otalgia .....

2. Motor Neuroses ....
Injuries of the Sound conducting Apparatus
Ear Disease and Life Assurance
The Diseases of the Naso-pharynx and of the Nasal Cavity

with Reference to the Diseases of the Middle Ear
Methods of Examination

1. Examination of the Nose .

2. Examination of the Naso-pharynx
Catarrh of the Nose and Naso-pharynx
The Adenoid VegetationB of the Pharynx and their Treat

ment ......

8EA8BS OF THE SoUND- PERCEIVING APPARATUS

I. Anatomy of the Inner Ear

A. The Labyrinth .....

1. The Osseous Labyrinth

2. The Membranous Labyrinth

a. The Saccules of the Vestibule
6. The Membranous Semicircular Canals
c. The Membranous Structure and the Terminal Ap<
paratus of the Auditory Nerve in the Oochlva
Bloodvessels of the Labyrinth ....

B. The Auditory Nerve .....

a. The Stem of the Auditory Nerve and its Dbtribution

in the Labyrioth
6. Central Course of the Auditory Nerve
The Topographical Relations of the Auditory Nerve and its
Nucleus ......

Origin and Central Continuations of the Auditory Nerve
Physiological Observations ....

VAf C

468
468
470
472
475
478
481

482
485
485
487
487

489
494
498

506

517
528
528
528

529
585

541
544
546
546
550
551
557

559
559
559
561
564

578

584
584
584
584
589
590
593

593
597

598

598
599

600
602
604

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CONTENTS.

II. DiSVASES OF THE LABYRINTH, OF THt AUDITORT NkRVB, AND OF

THE Cbntral Course of the Nebve . . . .610

Introduction .....
DiagnoBis of the Difleanes of the Auditory Nerve
The Diseases of Auditory Nerve Apparatus. Special

1. Hypersemia of the Lab3rrinth

2. Anaemia of the Labyrinth .

3. Haemorrha(i:H into the Labyrinth .
The Apoplectic Form of Meniere's Disease

4. Inflammation of the Labyrinth (Otitis Interna)
Panotitis .....

5. Leucocythaemic Deafness .

6. The Syphilitic Diseases of the Internal Ear

7. Diseases of the Auditory Nerve .
New-formations in the Internal Ear
Neurones of the Acoustic Apparatus

1. Hypereesthesias ....

2. Pareses and Paralyses
Injuries of the Internal Ear
Cerebral Disturbances of Hearing
Malformations of the Ear

Deafmutism .....
Instruments to assist the Hard of Hearing
Index of Literature ....
Index ......

Division

610
617
622
622
624
626
628
685
640^
642
645
649
654
659
659
668
676
684
697
705
708
71S
781

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ANATOMICAL DIVISION OF THE EAR

The sensations which we call perceptions of sound reach our con-
sciousness by the specific excitation of the peripheral expansion of
the auditory nerve. The delicate terminations of this nerve lie upon
membranous supports, which are surrounded by an aqueous fluid in
a cavity partly formed by rigid walls. These membranous supports
serve as a medium for the transfer of the waves of sound, which
reach the organ of hearing from the outer world, to the extremities
of the auditory nerve.

Beside the essential sound-perceiving apparatus, the higher
developed animals possess a sound-conducting apparatus which
possesses the property of receiving and conducting to the lab3ninth
the diflerent sound-waves.

According to the above observations, the organ of hearing is
divided into two principal parts, the sound-conducting and the
sound-peroehdng portions. As this classification is the only correct
one from the physiological standpoint, we will adhere to it for the
future, especially as the older anatomical divisions into outer, middle,
and inner ear can be reconciled with it.

After dividing the organ of hearing, then, into two principal parts,
as mentioned above, a further division takes place as follows :

1. The sound-conducting apparatus, in :

a. The external ear (auricle and external meatus).

b. The middle ear (the tympanic cavity with membrana tym-

pani and ossicula, Eustachian tube and mastoid process).

2. The sound-perceiving apparatus, the internal ear (labyrinth),
which consists of the vestibulum, the three semicircular canals, and
the cochlea, in which latter the peripheral expansions of the auditory
nerve are found.

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THE ANATOMY AND PHYSIOLOGY OF THE SOUND-
CONDUCTING APPAKATUS.

I. THE EXTERNAL EAR.

A. The Auricle.

The auricle presents in its outline a pyriform shape. Its normal
position is between two horizontal lines, of which the superior
touches the eyebrows, the inferior the tip of the nose. While it
surrounds the external orifice of the ear, it is fastened on the lateral
part of the head, midway between the forehead and the occiput, in
such a manner that it forms with the lateral part of the head towards
the occiput an acute angle, which is subject to manifold individual
varieties.

In this position the concave surface of the auricle, turned forwards aiid
outwards, shows a number of irregular elevations and depressions (Fig. 1).
The outer margin of the cartilaginous plate is turned in towards the front,
and forms the heUx of the auricle (Fig. 1, a). The helix, commencing at the
crista helicii, above the external orifice of the ear, in the most pronounced
depression of the auricle {concha) ^ extends from here along the margin of the
auricle upwards and backwards, and ends as processus helicis above the
posterior margin of the lobe. In parallel direction with the posterior part of
the helix, and separated from it by a depression, the so-called scaphoid fossa^
there extends a second elevation, the am^tiheUx (6). It commences above the
crista helicb with two crura diverging forwards (crura bifurcaia), and taking
its course downwards, it passes with a slight curve forwards into a promi-
nence of cartilage, the so-called anHtra,gus (d). Opposite to the last-named
part, and in front of the external orifice of the meatus, smrmounting it a little,
the cartilage of the ear forms a second nipple-like projection directed back-
wards, the tragus (c), which is separated from the antitragus by a notch
(ineisUra intertragica). Below this notch, forming the inferior extremity of
the auride, is the lobe {Johuhis^ e), which shows numerous individual varieties,
and in whose formation only the integument covering the auricle takes part.

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THE AURICLE.

The subcutaneous connective tissue is highly developed in this place, its
meshes containing globules of fat, but only a small number of bloodvessels
and nerves.

The external integument, covering the auricle, is fastened much more
tightly to the perichondrium on the anterior
than on the convex posterior surface, where
the subcutaneous connective tissue is more
strongly developed, and the skin therefore
more easily movable. Of the cutaneous
glands the sebaceous are very numerous in
the concha, and are also of a large size.
The cartilage of the auricle is about 2 nnii.
in thickness, and is of the^ reticulated
variety.

The muscles supplying the amicle are
divided into two groups. The first group
acts in such a manner that it effects a
movement of the whole auricle. The most
important muscles belonging to this group
are: 1. The attollena au/ricuUe, a fan-
shaped radiating muscle, which arises from
the epicranial aponeurosis, and with its
fibres converging in a downward direction,
attaches itself to the convex surface of the
auricle ; it draws the auricle upwards. 2.

The attrahens aniricuUe, which arises also from the epicranial aponeiurosis in
front of the auricle, above the zygomatic arch, and has its place of attachment
on the crista helicis ; it draws the auricle a little forwards and upwards. 8.
The retr<ihen9 aairiculee, which arises behind the auricle on the mastoid
process, consists of several fasciculi, and extends to the convex surface of the
concha ; it is intended to draw the auricle a little backwards. The second
group of muscles have their origin and place of attachment on the auricle
itself. They effect an alteration in the form of the auricle, but only to a
slight extent. The tragicus, antitragicus, helicis major and nvinor lie on
the concave surface, the tranaversus and obliquus auricuUe on the convex
surface of the aiuicle.*

Fig. 1. — AuBiCLC
a, Helix ; b, Antihelix ; c, Tragus ; d,
Antitragns ; e, Lobulus ; /, Concha ;
<7, Orifice of the external meatus.

B. The Extbrnai. Meatus.

The external meatus is divided into two portions, viz., the
cartilaginous and the osseous.

* * The new criminalistic school of Italy, of which Lombroso is at the bead, con-
sider the anomalies in the form of the ear as degenerative changes. Support is found
for this view by the extensive investigations lately made by Gradenigo (A. f. O., voL
XXX.), in which he found the anomalies of conformation of the auricle most frequent
among the insane and criminals.'

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CARXmAGINOUS MEATUS.

a. Its Cartilaginous Portion.

The cartilaginous meatus is a tubular continuation of the auricle
directed inwards. This canal, however, is not cartilaginous in its

whole extent, but consists of a
cartilaginous channel, which is
formed at its upper and back
part into a tube by a membranous
layer connected with the lining
membrane of the meatus.

The circumference of the car-
tilaginous channel (Fig. 2) appears
largest at its outer extremity,
while inwards the width of the
cartilage gradually decreases, so
that the inner extremity (b) ap-
pears as a narrow, rounded,
cartilaginous point.

This proportion of the cartilaginous
channel to the membranous part of
the passage can be shown in a simple
manner by sections (Figs. 8, 4, 5)
wliich are made perpendicularly to the axis of the cartilaginous meatus at the
outer, middle, and inner portions. We see, therefore, that the membranous
portion (6 in Figs. 3, 4, 5) increases in breadth towards the interior, while the
cartilage decreases. The length of the lower cartilaginous wall from the en-
trance of the meatus to the point of the cartilage varies from 10 to 11 mm.

The channel of the cartilaginous portion of the meatus, which varies in
thickness in different places from 1 to 3 mm., is traversed transversely by

Fig. 2.— Auriolv and Cabtilaoinous
Meatus.
a, Cartilaginous meatus ; 6, Interior
pointed (Extremity of the cartilaginous
meatus ; • e, c. Fissures of Santorini
(left ear).

Fig. 3.— Section or the
Cartilaginous Meatus

CLOSE BEHIND THE OrIFIOE

OF THE External Meatus.

a, a, a, Cartilaginous chan-
nel ; 6, Fibrous la} er.

FiG.4.— Section through

THE MmDLE OV THE

Cartilaginous Mba>

TUS.

a, a, a, Cartilaginous
channel ; b. Fibrous
layer.

Fig. 6. — Section in thk
Neighbourhood op
THE Interior Extrk-

MITT OF THE CARTILA-
GINOUS Meatus.

a, Cartilage ; 6, Fibrous
layer.

several fissures, the so-called fissures of Santorini (Fig. 2, c, c). As a rule,
two large fissures are found. These are, however, by no means regular and
constant in direction or extent. Tbey are filled up by a fibrous tissue, which
often contains small bundles of muscular tissue, and allows an anastomosis of

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CABTILAQINOUS M£ATU8. O

the bloodvessels between the anterior and posterior surfaces of the ear. They
are important because they favour the straightening of the meatus durin*;
the examination of the membrana tympani and during operations.

But in other respects also the fissures of Santorini possess a practical
interest. The inferior wall of the cartilaginous channel of the meatus is to
a great extent surrounded by the lobes of the parotid, so that in a parotitis,
ending in abscess, the accumulated pus may force its way through one of
these fissures into the external meatus. The medial end of the cartilaginous
meatus is fastened by means of a mass of connective tissue to the osseous
meatus, covered over with elastic fibrous tissue. This consoUdation, how-
ever, takes place only in that part of the external meatus formed by the
tympanic portion of the temporal bone, which we have still to describe ;
therefore it belongs to the inferior and lateral margin of the canal (Fig. 8),
while above, where the squamous portion curves at a right angle towards the
superior wall, the fibrous portion of the cartilaginous meatus passes without
interruption into the lining membrane of the superior wall of the osseous
meatus.

b. Osseous Meatus.

1. Its Development, — The anatomioal relations of the osseous
meatus are essentially different in the new-bom infant and in the
adult. In the infant we find, instead of the osseous meatus, an
osseous ring {annulus tyrtvpanicus) to the exterior margin of which
a membranous canal (v. Troltsch) is attached, forming one half of
the whole meatus. This part ossifies from within outwards during
the early years of life.

The formation of the osseous meatus is essentially connected with the
development of the temporal bone. According to the examinations made by
-\mold, the temporal bone is divided into three parts, which are separately
developed. These are called the squamous, the tympanic, and the petrous
portions of the temporal bone. The osseous meatus consists of two different
parts, and is principally formed by the squamous and tympanic portions of
the temporal bone.*^

The tympanic portion of the temporal bone in a child consists of a ring
(annulus tympanicus) (Fig. 6) with an opening upwards and forwards, and is
provided with a groove for the reception of the membrana tympani. This
ring is attached by its free extremities to the inferior part of the exterior sur-
face of the squamous portion. The space between the two places of attach-
ment of the tympanic portion to the squamous portion we shall know
by-and-by as the anterior superior grooveless segment of the tympanic ring
(Bivinian segment).

* In Du Verney'B TraiU de VOrgane de VOuie, 1781, plate iv., the perfect os
tympanicom aa principal constituent of the oeaeous meatus in the adult will be found
represented either in connection with the temporal bone or by itself. In the same
book, plate xv., there is a representation of the lately-discovered 9Utwra nuutcideo-
squamosa.

Digitized by VjOOQIC

DEVELOPMENT OF THE OSSEOUS MEATUS.

With the progressing growth of the cranial bones in the early years of life,
the following alterations take place in the squamous and tympanic portions.
While (Fig. 7) the jsuperior part of the squamous portion is placed on the

Fig. 6a.

7.— Temporal Bonb
Infakt.

NKW-Boay

Fig. 6b.

a, Superior part of the Bquamoos bone ; 6, Its
inferior part below the line of the zygomatic
process ; c, Annulus tympanicus ; d, d. The
fissure between squamous portion and mastoid
process, reaching to the foramen stjrlo-mastoi*
deum ; e. Foramen stylo-ma^toideum ;/, Fora-
men ovale ; ^, Fclramen rotundimi (left ear).

lateral part of the cranium, its lower portion (&), which lies beneath the Hue
of the zygomatic process, takes a more horizontal position, in such a way that
in the completely developed temporal bone the superior part of the squamous

portion (Fig. 9, a) is bent
almost at a right angle to its-
inferior horizontal portion (6) .
This horizontal portion forma
the superior wall of the
osseous meatus, and m con-
junction with the mastoid
process it also forms a part
of the posterior wall.

As mentioned above, an
essential part in this forma-
tion of the osseous meatus is
taken by the tympanic por-
tion of the temporal bone.
With its growth, through
deposit of osseous substance
on its exterior (Zuckerkandl), there arises an osseous groove (Fig. 8, b), the
lateral walls of which reach so far up in a median direction near to the
tympanic bone, that they also take part to a varymg extent in the formation
of the superior wall of the meatus.

Fio. 8.— OssBOUB Meatus in the Adult.

a, Horizontal part of the squamous bone (superior
part of the meatus) ; 5, Tympanic portion ;
c, Lumen of the meatus ; d. Mastoid process
(left ear).

Digitized by VjOOQIC

DEVELOPBfENT OF THE OSSEOUS MEATUS. 7

In the perfect temporal bone, therefore, the groove-like tympanic portion
(Fig. 8) appears as if pushed from below into the shallow sulcus (a) which,,
directed downwards, is formed by the horizontal part of the squamous bone
and the mastoid process. The inferior and anterior walls of the meatus are
therefore formed by the tympanic portion, while in the formation of the
posterior waU the squamous, mastoid and tympanic portions participate, the
first largely by the lamina mastoidea, which lies on the anterior surfiice of
the mastoid process.

Sometimes the tympanic portion lies so close to the squamous portion and
mastoid process, that their boundary lines appear almost efi&tced ; sometimcH
the margin of the tympanic portion is prominently set off from the squamous
portion and the mastoid process. Into the fissures thus formed prolongations-
of connective tissue descend, into which inflanmiatory and suppurative pro-
cesses sometimes penetrate, causing caries of the wall of the meatus. On the
other hand, in purulent affections of the meatus, I have seen the destructive
process spread through these fissures from the inside outwards, in which case
a loosening and detachment of the lining membrane of the posterior and
superior walls of the meatus took place.

2. Construction of the Osseous Meatus, — ^The osseous portion of the
external meatus comes into connection with the cartilaginous meatus
at its exterior margin, while at its interior, widened extremity,,
the membrana tympani is stretched out in a groove-like sulcus.
We distinguish in it an upper, lower, anterior, and posterior
wall.

The strongly developed superior wall of the meatus (Fig. 9, b) appears bent
almost at a right angle to the squamous portion (a) of the temporal bone, and
is formed by two osseous plates, the superior of which is turned towards the
cranial cavity, and the inferior towards the lumen of the meatus.

Of these plates, the upper one meets at the sutura petroso-squamosa with
the superior wall of the tympanic cavity, and further back with the roof of
the mastoid antrum; the lower reaches to the boundary of the tympanic
cavity, where it ends abruptly in a sharp grooveless edge (ma/rgo tympa/nicus
of the temporal bone), directed inwards and downwards, into which the upper
margin of the membrana tympani is inserted.

The superior wall of the meatus Ues in the region of the middle fossa of the
skull, so that carious destruction of this wall, with extension to the meninges,
may produce death.

The inferior wall of the osseous meatus (c) appears thick and compact in
the section. Its surface turned towards the meatus is convex from without
inwards, the greatest convexity being on the borders of the inner thilrd of the
wall of the osseous meatus, from whence the surface inclines rather steeply
towards the outside as well as towards the inside. In the neighbourhood of
the membrana timpani the convexity is turned into a considerable concavity
(Fig. 9), which deserves notice, because it, in conjunction with the membrana
timpani, the latter placed obliquely to the axis of the meatus, forms a space

Digitized by VjOOQIC

CONSTRUCTION OF THE OSSEOUS MEATUS.

(sinus of the external meatus, H. Meyer), in which smaU foreign bodies are
often lodged.

A comparison of the lengths of the superior and inferior walls of the meatus
shows that the superior wall extends farther outwards than the inferior, but
that the inferior (c) extends from 6-8 mm. nearer the middle line of the bodv
than the superior (6). By this, as well as by the unequal lengths of the
anterior and posterior walls, the oblique position of the membrana tympaiii
to the axis of the meatus is caused : a fact which must be taken into considera-
tion at the examination of the membrana tympani, as well as at operations.

The anterior wall (Fig. 10, a), compared with the other, is thinner, and in

Fio. 9.— Perpendicular Section (front)
THROUGH Osseous Meatus and Ttm-
PANIC Cavity.

a, Squamous portion ; 6, Superior wall of
the OBseouB meatus ; b', Dura mater ;
c, Inferior wall of the osseous meatus ;
df Meatus ; e, Membrana tympani with
the malleus ; /, l?ympanic cavity (left
ear).

Fig. 10.— Horizontal Section op the
External Meatus and Tympakic
Oavitt.

a, Anterior wall of the meatus ; b,
Posterior wall ; c, Cells of the mastoid
process ; d, Meatus ; e, Membrana
tympani ;/, tympanic cavity ; g, Sinus
transversua.

its longitudinal direction, especially at the boimdary of the inner third, is more
or less strongly bulged out towards the lumen of the meatus. It is 17-18 mm.
long, and extends inwards 7 to 8 mm. farther than the posterior wall.

The defects in the anterior wall of the meatus, which are seen during the
earlier years of life, arise, according to Zuckerkandl, from the rapid growth
of the tuberculum anterior and posterior of the tympani ring. By a bridge-
like union a space is formed, which, however, generally closes at the end of
the third year. Defects in the ossification are not infrequently met with in
the temporal bones of adults (Arnold, v. Trolsch).

The inner part of the cartilaginous meatus and the anterior wall of the bony
meatus lie immediately on the posterior part of the glenoid cavity. The
movement of the jaw produces thereby a change in the lumen of the cartila-
ginous meatus. Violence applied to the lower jaw may produce fracture of
the anterior osseous wall of the meatus.

The posterior wall of the osseous meatus is chiefly formed, in its inner por-
tion, by the tympanic portion of the temporal bone, its exterior portion,

Digitized by VjOOQIC

THE LINING MEMBRANE OF THE EXTERNAL MEATUS. U

however, being formed by the mastoid process. It extends farther outwards
than the other walls, especially the inferior and anterior.

During the growth of the temporal bone the cells of the mastoid proces
extend outwards along with the greater mass of the cellular spaces by Ijnng
behind the meatus. Towards the front the mastoid cells are, therefore, imme-
diately covered by the posterior wall of the osseous meatus, from which the
important relation of this wall to the mastoid process can be understood, since
caries in the latter often extends to the posterior wall, the necrosed cells being
cast out through the external meatus.

c. The Lining Membrane of the External Meattis.

The lining membrane of the external meatus, a continuation of the external
integument, is much stronger in the cartilaginous than in the osseous portion.
In the latter the cutis generally becomes more delicate and thin as it gets
nearer the sulcus of the membrana tympani ; only on the superior wall a
somewhat stronger band of the cutis extends towards the membrana tympani.
The dermic layer of the cartilaginous
portion, 1-2 mm. in thickness, is
plentifuUy supplied with hairs, into
the sacs of which grape-like seba-
ceous glands discharge themselvcb.
Near these glands, embedded in the
subcutaneous tissue, and closely
applied to each other, are the so-
called ceruminal glands {glandulce
ceruminaleSy sweat-glands of the
ear, according to Ausspitz) of a
yellowish-brown colour, which in
their formation belong to the tubular
glands. Just as in the sweat-glands
in other parts, the tube of these
ceruminal glands is coiled up
(Kolliker) ; it is 0*2 to 1*5 mm. in
diameter, and discharges either
directly into the meatus, or into the
upper portion of the hair-sacs by
means of a straight canal, 0*1 mm.
wide (Henle). The orifices of the
glands in the meatus can be ob-
served with the naked eye as closely
arranged small darkish points (Fig. 11, a, 6, c). These glands are con-
structed of a single layer of cubical epithelium, outside of which is a mem-
brana propria and a layer of smooth muscular fibres.

According to v. Troltsch, the glandular layer extends from the posterior
superior wall of the cartilaginous portion into the osseous meatus in the form
of a triangular space, several mm. long (Fig. 11, the place between 6, and c),
the point of which (c) is turned towards the membrana tympani. In the other

Fig. 11.— Posterior Wall ok the Car-
tilaginous AND Osseous Meatus.

a, Orificee of glands on the cartilaginous por-
tion : b, Boundary between cartilaginous
and osseous meatus ; c, Termination of the
triangular space occupied by the orifices
of the glands, which protrudes into the
osseous meatus.

Digitized by VjOOQIC

10 VESSELS AND NERVES OF THE EXTERNAL MEATUS, ETC.

parts of the osseous meatus the glandular elements are wanting, and the more
delicate cutis, firmly united with the periosteum, forms spirally-arranged
ridges (Eaufmann), lying close together and containing only a few papilbe
(Medic. Jahrbticher, 1866), which often become hypertrophied in inflam-
matory affections, and form the foundation of large compact polypi.

d. Vessels and Nerves of the Auricle and of the External Meatus.

The arteries of the auricle and of the external meatus spring from the
temporal and internal maxillary arteries. The anterior surface of the auricle,
as well as the exterior portion of the meatus, are supplied by the art, cmric,
ant 9up, and two to three art auric, anterioreg inferiorea, springing from
the art, temporal, superf. A branch of the a/rt OAiric. posterior, springing
from the external carotid, ramifies on the posterior surface of the auricle.
The blood-supply to the lower portions of the external meatus is provided by
the art. auric, proftrnda, a branch of the art. maxilla ris interna. The
smaller branches of the above-named arteries enter partly the intermediate
membranous layer, bridging over the margins of the cartilaginous groove,
partly the fissures of Santorini, and partly the fibrous connective tissue, by
which the cartilaginous meatus is fastened to the osseous portion. They then
ramify in the lining membrane of the external meatus, forming a fine capil-
lary network on the perichondrium and around the glands of the hair-sacs
and the sebaceous glands. A considerable vascular bimdle extends along the
superior wall of the meatus towards the upper margin of the membrana
tympani, where it passes on to the membrane with a sheath of connective
tissue, as will be described later on, extending along the posterior margin of
the handle of the malleus to its inferior extremity.

The veins of the auricle and of the external meatus show numerous varieties
in regard to their junction with the larger venous trunks on the lateral portions
of the head. The vence auric, a/nt.post. ajidi profund. unite chiefly with the
vena jiigularis externa and the mastoidea; not unfrequently, however, a
portion of the veins from the external ear join the vena temporalis and the
vena maxillaris interna.

On the whole, there is very httle known regarding the Ij-mphatic vessels
of the external meatus. It is, however, probable that they are very often
connected with the lymphatic glands lying upon the parotid under the meatus,
as there is frequently a swelling of the lateral cervical glands accompanying
inflanunatory affections in the meatus.

The nerves of the auricle and of the meatus come from the nervus fa^ciaUs,
which sends the n. a/uric. post, profundus to the posterior surface of the
auricle ; from the trigenwn/us, the third branch of which suppUes the skin of
the auricle and of the external meatus with some twigs of the n. a^'riculo-
temporalis ; from the plexus cervicaUs, which takes part through the n. auri-
cnla/ris m>a>gnus in the supply of the external ear ; from the n. vagus, which
assists in the supply of the external meatus through the ramus auricularis
vagi, discovered by Arnold, coming from the ga/nglion jugulars, entering the
posterior wall of the meatus as a considerable branch, and supplying the lining

Digitized by VjOOQIC

SIZE AND DIKECTION OF THE EXTERNAL MEATUS. H

membrane of the meatus. A large nervous branch extends from the superior
wall of the meatus to the membrana tympani.

e. Size and Direction of the External Meatus.

The capacity of the external meatus in the adult is subject to
many individual variations. The cartilaginous portion is often so
wide that the little finger can be inserted without trouble as far as
the osseous portion ; in others, again, the lumen is found narrowed
to the diameter of a goose-quill. The lumen of the cartilaginous
meatus, which, inside the orifice of the external ear, is 5 to 7 mm. in
diameter, gradually widens as it passes inward, especially posteriorly,
to 9 to 11 mm. It shows again a moderate narrowing towards the
place of union with the osseous portion (7-9 mm.), but suddenly
enlarges within the osseous portion. In childhood the cartilaginous
meatus is narrower than in the adult, and therefore examinations
and operations are generally more difficult. On the other hand, in
old persons a slit-like closure of the orifice of the external meatus
often takes place in consequence of atrophy and shrinking of the
cartilage.

The capacity of the osseous meatus also presents many individual varieties.

Its calibre gradually becomes less in passing from its external orifice (Fig. 9)

inwards, is least at the margin of the inner

third of the osseous portion (isthnms), and

again increases considerably in size from this

point towards the insertion of the membrana

timpani. In the section the lumen of the

meatus is somewhat rounded in appearance

towards the outside, and in the deeper portion

till above the isthmus more elliptic in form

(Fig* 12), the diameter of the ellipse not _ ^^ „

I , ^ ,. 1 , . ,.**i • V J * ^^^' 12.— Section of the

being perpendicular, but a uttle mclined for- External Meatus.

wards. It foUows from this, that the isthmus ^^ ^^^^^ ^j ^j,^ ^^^^ .' ^^ ^^^
is in that part of the meatus where the terior wall ; c, Mastoid cellB.
anterior and inferior walls display the greatest

convexity towards the lumen. As this is the place where foreign bodies
become wedged in, and where, if they penetrate deeper still, the greatest
obstacle is offered to their extraction, it is important to know that the dis-
tance of the isthmus (front) from the anterior margin of the membrana
tympani amounts to 7-8 nam. ; from the posterior margin, however (on the
posterior wall), only 1-2 nun. In case of attempts at extraction the instru-
ment can, therefore, be inserted along the superior and posterior walls only
with great caution, so as to avoid injuring the membrana tympani (v.
Trdltsch). The transverse diameter of the osseous meatus amounts at the
isthmus to 6 nmu ; at the interior and exterior extremities to 9-10 mm.

According to Bezold, the longer diameter at the commencement of the
osseous meatus is 8*7 mm., the shorter 6*1 mm. ; at the inner end, or rather

Digitized by VjOOQIC

SIZE AND DIRECTION OF THE EXTERNAL MEATUS.

on a section through the outer pole of the membrana tympani these diameters
are 8'1 and 4*6 mm. respectively.

The lengths of the different walls from the external orifice of the ear to the
insertion of the membrana tympani are unequal. V. Troltsch in his measure-
ments assumes as the exterior boimdary of the meatus a sagittal plane, passing
through the posterior margin of the orifice, and according to him the length
of the superior wall amounts to 21 mm., that of the inferior to 26 nun., that
of the anterior to 27 mnx, and that of the posterior wall to 22 mm. On an
average the length of the whole meatus is 24 mm., of which more than one-
third is taken up by the cartilaginous portion.

The meatus in its course from the external orifice to the mem-

d c

Fig.

/ *

13.— Horizontal Skction of the Extk&nal Meatus.

a, Ck>ncba ; 6, Tragus ; c, Place of attachment of the cartilaginous portion ; c2, Mas-
toid process ; e, Anterior wall of the meatus ; /, Sin. meat, audit, extern. ; </,
Membrana tympani ; h, Tympanic cavity (left ear).

brana tympani displays several curves, which deserve full considera-
tion in regard to examinations of the membrana tympani, as well as
in respect to operations in the meatus. Although the whole meatus
appears spirally twisted about its axis (Fig. 14) it may on the whole
be assumed that the cartilaginous portion in passing inwards turns
backwards and upwards, the osseous portion forwards and down-
wards.

The longitudinal axes of the two portions of the meatus therefore
form an open angle forwards and downwards, and as the meatus
from the place of union of the two portions slopes both outwards
and inwards, the inferior part of the external orifice and of the
membrana tympani must lie lower than the other parts of the
meatus.

According to the observations of Laufel and Symington, in the new-bom
the lumen of the meatus is wanting in the inner segment, as the membrana

Digitized by VjOOQIC

THE MIDDLE £AB.

tympani lies with its whole surface upon the inferior wall. This condition is
favoured on the one hand by the outward and upward direction of the meatus,
and on the other, as v. Troltsch rightly observes, by the strongly developed
layers of epidermis on the membrana timpani and the meatus.

II. THE MIDDLE EAR.
The middle ear, the most important part of the ear from a patho-
Ic^cal point of view, is divided into — (1) The tympanic cavity ;
(2) the Eustachian tube ; and (3) the mastoid process.

A. The Tympanic Cavity.

The tympanic cavity is an irregular, three-sided, prismatic (Henle)
cavity (Fig. 9,/), compressed from without inwards, in which the
diameters from above down-
wards, and from before back-
wards, are greater than from
without inwards. Although
the walls forming the cavity
are in some places not sharply
defined, it is necessary for a
clear representation of the
anatomical facts to describe
these different parts as walls
of the tjonpanic cavity. We
will therefore commence with
a description of its exterior
wall, and the first subject for «^
our attention will be the mem-
brana tympani, which forms
the greater part of this wall.

The names of the walls of the Fiq. 1 4 —Corrosion Cast of thk Auriclb
tympanic cavity— exterior, in- and ov the Extkbnal Auditory Canal.

terior, superior, and inferior— are (After ezold.) •«*^^„,^.i:. . ^

^ . T ..,,,, . , , 8. FoBsa BCftphoidea ; *, Ft>88a mtercniralis ; c,

not m keepmg with then- actual ^pper, c'. Lower portion of the concha ; «,

positions, as the direction of the Second bend of the external meatus ;<, Border

cavity from above downwards is ^f the ty^P^'^j^.J^^^^^f^^i.**^' Jj/^^i
•^ ,. , , , . &, Depression of the membr. Sbrapnelli, and

not perpendicular, but extends m ^^ the proc brevi*.
an obhque direction downwards

and inwards (towards the middle line). If we adhere to the old names it is
necessary', owing to the important practical significance of these relations,
never to lose sight of the fact, that in the normal position of the head the
exterior wall becomes an exterior inferior by its inclination ; the interior wall,
which completely roofs the exterior wall, an interior superior ; the inferior
wall an inferior interior ; and the superior wall a superior exterior.

Digitized by VjOOQIC

THE MEMBRAMA TYMPAMI.

a. The Membrana Tympani.

The membrana tympani appears at the inner extremity of the
osseous meatus as an irregularly oval membrane, concave out-
wardly, and placed obliquely to the longitudinal axis of the meatus.

The margin of the membrane is embedded in a groove-like salens (sulctM
tym^cmicus), situated at the inner end of the meatus. This sulcus belongs
to the tympanic ring (Fig. 6) already mentioned, and exists on the perfect
temporal bone (Fig. 15) only to the extent of the part taken by that ring in
the formation of that bone. In front and above, however, at the so-called
Bivinian segment (Fig. 15, 5), the sulcus is wanting altogether, and the pars
flaccida of the membrana tympani is here united partly to the grooveless
margo tympanicus and partly to the ligam. malleus extemus.

Form of the Membrana Tympami. — The form of the membrana tympani
varies between the elliptic, the irregularly oval,
and the heart-shaped forms. Especially at ^wo
places the membrane is bulged out towards the
periphery-, viz., behind and above, into a large
segment of a circle (Fig. 15, c), and also as the
Kivinian segment at the anterior superior pole
(Figs. 15, 6, 16, c, and 17, b) of the membrane
above the short process of the malleus. This
segment is marked off from the remaining
periphery of the sulcus of the membrane by two
more or less sharply -defined angular projections
(Figs. 15 and 16), the distance of which from
each other at the base amounts to 2^-8 mm.,
the height of the rounded protuberance being
about 2nmi. (Prussak).

Size of the Mem>bra/na Tympani. — The size
of the membrana tympani presents more or less
noteworthy deviations in different individuals.
From numerous measurements taken by me, it
appears that the greatest longitudinal diameter
from the point of the spina ty^npamea po$U to
the lowest point of the inferior margin of the
membrane amounts to 9|-10 nun., the greatest
transverse diameter from the anterior to the posterior margin measures
8^.9 nun. Bezold's measurements, made on specimens prepared by corrosion,
give the average of the two diameters as 9*2 and 8*5 nun. ; the thickness of
the membrane between the handle and the tendinous ring, according to Henle«
amounts to 0*10 nun.

The Inclination of the Membrana Tympa/ni. — The inclination of the
membrana tympani depends in the adult on the inclination of the sulcus
tympanicus to the axis of the meatus. The inclination of the plane of the
sulcus will of course be greater the farther the anterior and inferior waUs of
the meatus reach inwards beyond the posterior and superior walls (Figs. 9

Fig. 15.— Sulcus ok the
Mbkbrana Ttnpani at
THE Innbb Extremity of
THE Meatus.

a, SulcoB ; 6, Anterior tu-
perior grooveless bulging
out of the peripherv of the
membrana tympani (margo
tjmpanictiB) or Rivinian
segment ; c, Osseoas wall
of the tympanic cavity be-
hind the membrana tym-
pani ; df Exterior wall of
the cavity extending into
theEostachian tnbe. (Kight
ear.)

Digitized by VjOOQIC

CURVATURE OF THE MEMBRANA TYMPANI. 15

and 10). Bezold*8 measurement on corrosion preparations gives the average
angle as 27-85°. V. Troltsch places the angle which the plane of the mem-
brane forms with the superior wall of the meatus at an average of 140^.

Dr. J. PoUak maintains that there is no perceptible difference between the
inclination of the membrane in the new-bom infant and in the adult.

Curvature of the Membrana Tympani, — In the above-described oblique
position the membrana tympani is not stretched out as a plane surface, but is
curved in such a manner that it turns its concavity outwards, and its con-
vexity towards the interior of the tympanic cavity (Fig. 9, e). The deepest
pajrt of the curvature, the so-called wmbo, corresponds with the inferior
extremity of the handle of the malleus, which is enclosed in the layers
of the membrana tympani. By the traction of this handle inwards the

--/

h a € ti

Fio. 16.— External Surface ov the Membrana Ttmpani (Natural Size).
a. Short prooen of the malleas ; 6, Inferior extremity of the handle of the malleus
(umbo) ; c, Membrana flaccida Shrapnelli ; c2, Oavitas glenoidalis ; e. Mastoid pro-
oen ; /, Section of the zygomatic process. (Right ear. )

membrane appears hollowed out in a funnel-shaped manner. The interior
convexity is common to the membrana tympani as a whole, but on closer
observation it is seen that the anterior and inferior portions of the membrane,
extending from the umbo towards the periphery, show a slight curvature with
external convexity (Fig. 9). This partial bulging out, as opposed to the
eurvatiure of the membrane, is due partly to the drawing inwards of the
membrane by the traction of the hcmdle of the malleus, partly to the action
of the circular fibres upon the radiating fibrous layers (Helmholtz). That
portion of the membrane which is situated behind the handle of the malleus
appears more relaxed, and shows a less regular curvature than its anterior
and inferior portions.

The shaft-like handle of the malleus (Figs. 16 and 17), intimately united
with the layers of the membrane, and strongly inclined inwards, extends in
an oblique direction from the front and above, backwards and downwards,
and ends at the umbo in a flattened extremity.

The handle of the malleus, which divides the membrana tympani into two
unequal portions, a lesser anterior one (Fig. 17, v) and a larger posterior one
(A), extends forwards and upwards to the short process of the same bone
(Fig. 16, a). This short process is recognisable on the membrane by a strongly-

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EXTERNAL SURFACE OF THE MEMBRANA TTMPANI.

marked, partially-pointed projection at its anterior superior pole. Before and
behind this pole are two folds, due to the partial bulging forwards of the
membrane. These folds are of a more or less decided character, and when
the membrane is abnormally concave they often have the appearance of gray,
tendinous bands. We will show their important diagnostic significance in
describing the pathological conditions of the membrana tympani.

At the anterior superior pole of the membrana tympani, near the folds and
above them, there are also to be foimd two short, tightly-stretched strise, which
take origin in the comers of the segment of Bivini, and extend, converging
towards each other, to the point of the short process (Fig. 17, «, «). These strisp,
which were first described by Prussak,
and which in examinations made
during life are often visible as marked
white lines, appear somewhat sunken
in dried preparations.* The portion of
the membrane (Fig. 17, ms) which is
bounded by these strise and the groove-
less fissure, is generally called the
membrana flaccida Shrapnelli, It is
much thinner and less tense than the
other parts of the membrana tym-
pani, and it appears therefore above
the short process as a small, pit-like
depression, and forms the outer wall
of a small space, commimicating with
the tympanic cavity, which is called
Prussak's cavity.

As regards the interior surface of
the membrana tympani, the rounded
head of the malleus, and the incus
connected with it by a joint, come
first into \dew above the membrane
(Fig. 18, a, d, g). Below the head
of the malleus is the neck, from

which proceeds downwards and backwards the handle (Figs. 17 and 18).
The latter is closely connected with the membrane ; indeed the bulk of the
liandle bulges out over the surface of the membrane, so that it appears as if
it were lying on it. On separating the incus from the malleus, there will
be found a fold on the posterior segment of the membrane, which has been
described by v. Troltsch. It begins from a slightly roimded ridge of bone
lying in the sulcus, and from the posterior superior part of the angular pro-
jection of the annulus t^inpanicus projects forwards, till it fastens itself to
the posterior surface of the handle of the malleus. Standing out from the
membrana tympsuai with a free inferior margin, this fold forms with the
surface of the membrane the posterior pouch of the membrana tympani
(v. Troltsch, Fig. 18, /), the relations of which are shown in the accompany-

* Superior strise for the attachment of the membrana tympani (Uelmholtz).

Fig. 17.— Outer Subfaob ok thk Lbft
Tympanic Membrane of an Addlt,

ENLARGED 3^ TiMES.

V, Segment of the tympanic membrane
lying in front of the handle of the

. malleus ; h. Posterior segment of the
tympanic membrane ; «, »', Prussak's
strise, passing from the abort process of
the malleuB to the spina tymp. post, et
minor ; ms, Membrana ShrapnellL

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MICB08C0PIC ANATOMY OF THE MEMBBANA TTMPANI. 17

ing eut (Fig. 19). The smaller anterior pouch is enclosed by an osseous pro-
jection from the neck of the malleus, the ligamentous and osseous remains of
the long process of the malleus ; by the chorda tympani, the aai&r. tyrrvp, imf,
and the lining membrane. The superior boundary of the anterior pouch is
formed by the gray stria extending from the short process to the anterior
angular projection of the annulus tympanicus (Prussak). The constant
occurrence of the aperture at the superior anterior pole of the membrana
tympani, described by Eivinus (1689), and corroborated by Bochdalek (Prager
VierteljahrscTMrift, 1866), is in nowise proved.

Mierotcqpic Anatomy of the Membrcma Tympcmi, — As was known to
older investigators, the membrana tympani consists essentially of three

/-
d

FlO. Id.^lNTBBlTAL SUBFAOE Or THE LkR MiMBBANA TtMPAKI (EnLABOKD).

a, Head of the malleus ; 6, Neck of the malleiu ; e, Tendon of the m. tensor tympani
and anterior fold of the membrana tympani ; d^ Inferior extremiW of the handle
of the malleos ; e. Anterior portion of the membrana tympani ; f Posterior fold
of the membrana tympani and chotda tympani ; g^ Inoos ; A, Short process of the
incus ; i, Long process of the inoos.

principal layers, a middle fibrous layer, the lami/na propria^ an external
dermic layer, and an internal layer of mucous membrane, the two last named
being the coverings which the lamina propria receives from the lining mem-
brane of the external meatus and of the tympanic cavity. The dermic layer
may be easily detached from the fibrous, but the internal layer is so closely
connected with the fibrous, that it is not possible to separate them.

The dermic layer consists of several strata of pavement epithelium with a
Malpigbian mucous layer, but possesses only a very slight stratum of con-
nective tissue, which appears to furnish a constant covering for the vessels
and nerves of this layer.

We have ahready mentioned that, especially in the new-bom infant, a
strongly developed cutaneous band extends from the superior wall of the
external meatus to the membrana tympani and behind the handle of the
malleus, so that between the handle and the cutaneous band there is left a

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MICBOSCOPIC ANATOMY OF THE MEMBRANA TYMPANI.

triangular transparent space, directed with its apex towards the extremity of
the handle; with this cutaneous band, consisting of connective tissue and
elastic fibres (Prussak's descending fibres), there also extend vessels and
nerves from the meatus to the membrana tympani. At the inferior and
widened extremity of the handle of the malleus, the ligamentous fibres of
this bundle radiate towards the periphery, and partly unite with the fibres of
the substantia propria.

The middle fibrous layer consists of two separable lamellae, an external
radiating layer, and an internal circular layer. The pale, filamentous and
delicately defined fibres of these two layers form a tissue, which, according to

Fig. 19.— Section thbough ti}b Malleus and the Postbbiob Ttvpanic Pouch
AT the Level of the Short Pbooess of the Malleus.

A, Malleus ; &r, CartilaginouB portion of its short proceas ; tr, Posterior portfon of
the typapanic membraDe ; fa. Posterior fold of the tympanic membrane ; to,
Posterior pouch of Von Troltsch ; s, Mucous lining of the tympanic cavity.

Gerlach, is, so to say, midway between the usual fibrillated and the homo-
geneous connective tissue of Beichert. According to the embryological inves-
tigations of Draispul the lamina propria of the membrana timpani is a
durect continuation of the periosteum of the annulus tympanicus. The outer
radiating fibres partially cross, and are principally at the lower part, and
attached to the enlarged end of the handle of the malleus (Fig. 20, v). In
the upper portion are only a few fine fibres at the anterior border of the
handle of the malleus. They become at the same time more dense towards
the centre, partly because they multiply by splitting of the fibres (Gerlach),
and partly because they thicken at the umbo by accumulation in the limited
space (v. Troltsch).

The inner lamella consists of fibres which, from their circular arrangement,

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MICKOSCOPIC ANATOMY OF THE MBMBBANA TYMFANI.

11)

cross the direction of the radiating fibres. At the margin it is closely con-
nected with the origin of the radiating layer ; both layers, however, are easily
separable from each other from this point to the handle of the malleus. The
fibres of the circular layer, which can be traced to the tendinous ring, are
wanting on the external margin of the membrana tympani. They collect
themselves and are most dense within the tendinous ring, which consists of
compact fibrous connective tissue, while they become more sparse towards
the centre. The circular fibres go more to the external surface of the handle
of the malleus above, on account of which the handle appears more
prominent on the inner surface. A crossing and amalgamation of the fibres
from both sides of the malleus han41e appears to take place only at the
lower third. This portion of the hammer is most closely united with the
membrana tympani, while above a large portion of the external surface
of the handle is lying on the y^

membrana t;>inpani, and the
connection is less secure. Be-
tween the fibres of the two layers,
the corpuscles of connective tis-
sue, called Troltsch's corpuscles
after their discoverer, are seen
spindle-shaped in the longi-
tudinal sections, and star-like in
the transverse. They are very
similar to the corpuscles of the
cornea, their delicate processes
anastomosing with each other,
and spreading on either side to-
wards the vascular cutaneous
layer and the layer of lining
membrane, to draw from them
their nutrition. According to
V. Troltsoh, the cells of the
epithehal surface of the lining
membrane are connected by pro-
cesses with the corpuscles of the
membrana t^'mpani ; Prussak has confirmed the occurrence of the spindle-shaped
fibres in the membrane (organic muscular fibres) described by Everard Home.

The inner layer, a continuation of the lining membrane of the tympanic
cavity, is closely united with the circular fibrous layer, and consists of a very
scanty stratum of connective tissue with a covering of non-ciliated pavement
epithelium. Gerlach has found on the lining membrane of the membrana
tympani, in not inconsiderable quantities, projections like the villi of the
intestine, covered with a layer of flattened cells, and they contain one or
more capillary clusters. They occur in greatest numbers on the membrana
tympani of the new-bom infant.

The fibres of the substantia propria are la,ckingin the membrana Shrapnelli,
and it consists of delicate interla,cing fibres of connective tissue covered
externally by a thin cuticular layer, and internally by the mucosa of the

Fio. 20. — Seousnt or the Lowsb Pobtion

OF Tus Ttmfanio Mkmbrans.

A, Handle of the malleoB ; r, Layer of radiating

fibres ; c. Layer of circular fibres.

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20 MICROSCOPIC ANATOBCY OF THE MBMBRANA TTMPANI.

tympanum. It is penetrated by bloodvessels which are inconstant in their
course and anastomosis.

The membrana t^-mpani possesses two vascular networks, separated by the
substantia propria, and anastomosing with each other at the periphery, the
outer one belonging to the connective tissue of the cutis, the inner to the
mucous membrane.

The vascular network of the cutis comes from the arteria aiuicularis profunda,
which sends a branch to the centre of the membrana tympani. This branch
lies between two venous branches, which form a plexus here and there, and
descends to the lunbo from the superior posterior wall of the meatus, behind
the handle of the malleus. These vessels do not lie inunediately behind the
handle, but at some distance from it, in such a way that between them and
the bone a portion of the membrana tympani is visible, its point directed
downwards. At the centre of the membrane the arteries as weU as the veins
communicate by numerous radiating branches with a vascular zone, situated
at the periphery of the membrane, and through this also with the vessels of
the tympanic cavity (Moos, Archiv. /. Augen. und Ohrenheilk,, vol. vii.).
According to Moos, anastomosing bloodvessels perforate the membrana
tympani in the region of the hanmier and at other places. According to the
investigations of Prussak, the veins are in greatest numbers at the handle of
the malleus, as well as at the periphery. The arterial branches which run
along the handle of the maUeus, partly enter at once into the venous plexus
in the neighbourhood, and partly pass across the membrana tympani to the
marginal venous zone. Burnett found vascular loops alwa^'s present on the
membrana tympani of the ox, the oat, and the goat.

The veins of the cutaneous layer of the membrana tympani are connected
partly with the veins in the external meatus, partly, on the periphery of the
membrana tympani, with the vessels in the tympanic cavity through apertures
sometimes of considerable size.

The vascular network on the surface of the lining membrane springs from
the vessels of the tympanic cavity, and presents a rather closely meshed
capillary system, developed from an artery which runs parallel to the handle
of the malleus, on the inner side of the membrana tympani (Moos). The
lymphatic vessels of the membrane, according to Kessel (Handhtuih der Lehre
von den Qewelen^ 1870), are, like the bloodvessels, arranged in three layers
anastomosing with each other. If the epithelium of the lining membrane be
brushed off, with a low microscopic power, a fibrous framework (designated by
Gruber dentritic formation) will be found lying upon the substantia propria,
which is often spread over the whole membrane, but is especially developed
on that part situated behind the handle of the malleus.

From the membranous expansion of this fibrous framework, which is inter-
rupted here and there (Fig. 21, a) by large and small interspaces, there radiate
towards the handle of the malleus, as weU as towards the peripheral tendinous
ring, processes which form curves of different sizes. These processes strike
deep and amalgamate with the fibres of the substantia propria. According
to my own investigation a similar formation is to be found in the mucous
membrane of the cavum tympani, and consequently it cannot be considered
a structural peculiarity of the membrana tympani.

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LYMPHATIC TE88ELS AND NEBVE8 OF THE MEMBBANA TYMPANI. 21

The nerves of the membrana tympani, which, according to Arnold, spring
from the nervtu temporalis superficialis of the trigeminus^ but which were
minutely examined for the first time by v. Troltsch, are spread out on the
external layer, parallel with the vessels, in the form of three or four very
delicate, ill-defined branches, the terminations of which are, so far, unknown.
Keesel says that he has sometimes observed round the vessels and between
their meshes a large nervous plexus and gangliar swellings on the nerve-
filHres. In the rete Malpighii there is a second plexus supplied with multipolar
cells. The nerve-fibres of the cutis, while regularly dividing dichotomously,
penetrate the substantia propria and come into connection with the nervous
plexus of the lining membrane. Gerlach observed delicate non-medullated

Fio 21.— Fibrous Framework of thb Posterior Sbouknt of the Interior

SURFAOE or THE MrMBBAWA TtMPANI IH THE AdDIT.

a. Great iiiter»pace in the framework ; 6, Small interspace, thioagh which a thin
process pMses ; c, Aroh formed by rsdiatiDg processes.

nerve-fibres in the covering of the lining membrane. Forming the external
wall of the eavxmi tympani, besides the membrana tympani, is a margin of
bane ; bordering on it and above is a smooth cup-shaped niche, which serves
to hold the bodies of ihe hammer and incus (Logette de$ Osselets^ Gell^).

b. Superior Wall of the Tympanic Cavity,

The superior wall, or roof, of the tympanic cavity is formed by an osseous
plate, continuous with the superior surface of the p^Tamid. This plate extends
beyond the boundaries of the tympanic cavity, forming not only a part of the
superior lamella of the osseous meatus, but also ihe upper waU of the mastoid

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SUPERIOR WALL OF THE TYMPANIC CAVITY.

antrum, and the roof of the canal for the tensor tympani, and of the osseous
portion of the Eustachian tube.

In the ear of the infant, on the upper wall of the tympanic cavity will be
found a suture (sutura petroso-aqtia/mosa), which is formed by the meeting of
the roof of the tympanic cavity with the inner lamella of the squamous
portion of the temporal bone. Through this suture, in the new-bom infant,
processes of connective tissue, containmg bloodvessels, pass from the dura
mater into the t^onpanic cavity (Wagenhauser). This explains why children
suffering from acute tympanitis often exhibit symptoms of meningeal irrita-
tion, the hypersemia in the tympanic cavity spreading by means of these
vascular connections to the dura mater.

In the adult this suture is firmly closed, and with the exception of a few

traces, the connective tissue processes
have disappeared. It is indicated on
the macerated bone by a jagged
furrow, and is not situated above the
tympanic cavity, but for the most
part above the osseous meatus. The
projecting curved process of bone on
the under surface of the tegmen
{Crista trcmaversa tymjp., Bezold)
serves for the attachment of a fold
of mucous membrane, which is con-
nected with the tensor tendon.

The thickness of the superior wall
of the tympanic cavity above the head
of the malleus amounts to 5-6 mm.
Sometimes the roof is formed by a
thin osseous plate, but often it is
thickened by a cellular osseous sub-
stance ; it is, however, much thinner
than the superior wall of the meatus.
The space due to the difference in thickness of the superior wall of the osseous
meatus and the superior waU of the tympanic cavity, and in which the head
of the malleus and the body of the incus are situated, is called the upper
space of the tympanic cavity (attic of the tympanum, cavum epitympanium).
An examination of a large number of macerated crania will often show that
tlie deUcate transparent osseous plate of the roof of the tympanic ca\ity is
defective, being pierced by one or more irregular apertures, and that some-
times a great part of the roof of the tjinpanic cavity may be wanting.*

r a

Fio. 22.— Frontal Seotion thbough the
ExTSBNAL Meatus, Ttmfanuu and the
Labyrinth of an Adult.

me. Meat, audit, extern. ; c^ Cavum tymp.
with the tympanic membrane, the ossi-
cular chain and the tensor tendon ; tg,
Tegnien tymp. ; v, Vestibale ; mi, meat,
audit intern. After a preparation in
my collection. The aunolus tymp. and
the tympanic membrane are preserved
intact (Left ear.)

c. Inferior Wall of the Tympardc Ccwity.

The inferior wall of the tympanic cavity is narrower than the superior. It
is limited behind by the posterior wall, and before by that gentle elevation of
the inferior wall towards the anterior, which is situated below the ostimu

* This anomaly, which is designated by Hyrtl as spontaneous dehiscence of the
tegmen tympani, is probably due to arrested development.

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POSTEBIOB WALL OP THE TYMPANIC CAVITY. 23

t^mpanicum tubas. Its surface usually presents ridges and hollows,* but is
often smooth and bulged forward towards the tympanic cavity by the adjoin-
ing fossa jugularis. Its thickness varies in the same manner as that of the
superior walL

The proximity of the inferior wall of the tympanic cavity to the fossa
jugularis is worthy of remark, because a fatal phlebitis with thrombosis in the
bulbus venae jugularis is often brought about by caries of this wall.

A Posterior Wall of the Tympanic Camty.

The height of the posterior wall, rising abruptly from the floor of the tym-
panic cavity (Fig. 28), amounts to several millimetres. Above it there is
a great triangular aperture, which is the means of communication between

FlO. 28.— VmW of THl PoSTEBIOB WaU* OP TH« TYMPANIC CaVITT.

a, Meatus ; b, b', Superior and inferior walls of the meatos ; c, Superior wall of the

r panic cavity ; d, Protaberance underneath the eminentia stapedii, caused bv
superior extremity of the stvloid process ; e, Posterior wall ; /, Entrance into
the mastoid process ; g, Eminentia stapedii ; h, Ganalis Fallopiee ; i. Interior meatus.

the tympanic cavity and the mastoid process. In the inferior angle of this
aperture a saddle-shaped notch will be found, in which rests the short process
of the incus. From the surface of the posterior wall there arises a small
osseous projection, directed forwards, on the pointed extremity of which
a delicate and rounded aperture is visible. This is the eminentia pyra-
midoMs (g), which is connected with the Fallopian canal by one or more

* In this wall also dehitoences have been observed similar to those in the superio
wall (Friedlowsky).

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124

POSTEBIOB WALL OP THE TYMPANIC CAVITY.

fissures, and which encloses the muscle of the stapes, the tendon of which
passes through the rounded aperture to the capituliun of the stapes.

Below the emmentia stapedii very often a more or less pronounced
irregular protuberance (d) will be seen, which, as I was the first to prove,* is
caused by the bulging out of the superior extremity of the styloid process
{ptotuheranHa styloidea,) This process, which according to Ghradenigo is
composed of two parts, an upper and a lower, and is stated by Reiehert to
originate from the second branchial arch, is mostly quite cartilaginous after
birth, and ossifies only in the course of the first year. As first described by
me, the shape of its superior portion in the new-bom infant (Fig. 24) is that
of a club, the upper knobby extremity of which is located underneath the

Fio. 24.— STTLom Prookk
IN TBx New-born Infant.

a, Superior extremity
pointea towards the pos-
terior wall of the tympanic
cavity; 6, Club-like ex-
tremity pointing back-
wards ; c, Short cartilagi-
nous prooeM ; d^ Inferior
extremity.

Fio. ift>— Sbotion of STYLoro Pbocbss in the
Adui/t.

a, Memfarana tympani ; b. Medullary cavity of the
styloid process ; c, Its superior extremity with the
protuberance on the posterior wall of the tympanic
cai^ity.

eminentia stapedii. .The rounded extremity of the club (b) is pointed back-
wards, and rests in a oup-shaped depression of the mastoid antrum, directed
forwards. This small cavity (|mm. in diameter) on the anterior portion of
the mastoid cells I have found at different times in the macerated temporal
bones of new-bom infants, the superior extremity of the styloid process not
yet having been ossified or united to the mastoid process on its posterior
boundary. So far as I know, this small, cup-shaped cavity of the mastoid
process in the new-bom infant was first observed by me.f
The ossification of the styloid process commences at its superior extremity,

* Arch,/, OhrenheUk,, voL x.

t Politzer, The AnatomiccU and Histological Dissections of the Human Bar^ p. 49,
Fig. 62, c.

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ANTEBIOB WALL OP THE TYMPANIC CAVITY. 26

often before birth. By carefully opening the sheath of this process in the
macerated temporal bone of the new-bcnn infant, it will therefore often be
f onnd that its uppermost ossified portion is firmly united with the bone at the
place where the above small cavity is situated.

The projection on the superior extremity of the styloid process, which is
directed forwards, is adjacent to the posterior wall of the tympanmn, and
often presses it forwards in the shape of a rounded swelling against the lumen
of tiie tympanic cavity.

In the adult I have also succeeded in tracing the styloid process to its upper-
most extremity. In carefully made sections (Fig. 25), I foimd the cortical
substance of the styloid process closely united with the surroimding osseous
tissue ; and I could trace the medulk^ space (b) to its superior extremity,
bordering on the posterior wall of the tympanic cavity.

e. AnterUyr Wall of the Tympanic Cavity,

The anterior wall of the tympanic cavity is formed only by the short, ridgy,
and oblique plane which rises at the anterior boundary of the inferior wall
(Fig. 26). Above this plane, on the same level as the entrance into the
mastoid process, a large irregular aperture, the ostium tympanicum tubte.
leads into the osseous Eustachian tube, which lies immediately below the canal
for the tensor tympanL The ridgy, sometimes dehiscent, anterior wall of the
tympanic cavity is closely aj^ed to the carotid canal. According to a number
of observations, a sudden fatal hemorrhage may occur from caries of this
wall opening the carotid artery. The walls of the carotid artery do not, how-
ever, lie close to the osseous canal, as they are surrounded by a venous sinus,
which is connected with the sinus cavemosus, as was first proved by Kektorzik.

/. Inner Wall of the Tympanic Cavity,

The relations of the inner wall, or labyrinth wall, of the tympanic cavity
(Fig. 26) are more complicated. In it there are two fenestrse, closed by elastic
plates, and leading to the labyrinth, the great importance of which in the
physiology of the ear we shall see later on. The oval or bean-shaped fenestra (a) ,
whidi leads to the vestibule of the labyrinth, and is situated at the extremity
of a deep niche, receives the foot-plate of the stapes. This niche is called the
pelvis ovalis, and, as we shall see, is very often the seat of pathological
changes. The greatest diameter of the aperture (8*5-4 mm.) extends from
before backwards and downwards ; the height from without inwards and
downwards is 1^ to 2 mm. The plane of the fenestra ovalis is therefore
strongly inclined towards the axis of the ear. The upper border of the fenestra
ovalis is strongly convex, while the lower is slightly concave. The anterior
rounded end is much wider than the posterior, at which the upper and lower
borders meet with a sharp bend.

Below the fenestra ovalis (at a distance of 8-4 mm.), the entrance to the
niche of the fenestra rotunda (Fig. 26, b) will be seen, directed backwards.
In an obliquely-placed groove at its base, a small, delicate membrane (metn-
brana feneBtra rotunda nve memb, tymjp. secundaria Scarpa), somewhat

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INNER WALL OF THE TYMPANIC CAVITY.

concave towards the membrana tympani, is stretched out, which shuts out the
cochlear canal from the tympanum. The height varies from 1*6 to 8 mm.,
the lyidth from 1 to 8 mm. Between the niche and the eminentia pyramidalis
is a depression in the wall, varying in size in different individuals (8inu» tytnp.,
SteinbrUgge).

Between and a little in front of the two fenestrse, the wall of the tym-
panimi is strongly bulged out towards the cavity; this is due to the projection
of the first whorl of the cochlea, and is called the promontory. Vertically
above it, in an open or covered groove, extends Jacobson's nerve, which
comiects the jugular ganglion with the n. petrosus superf. minor. A number
of inconstant winding furrows show the coiurse of the nerve branches of the
plexus tympanicus in'the mucous membrane covering the promontory.

Above and slightly behind the fenestra ovalis there is seen a portion of the

d b c
Fio. 26.— Inner Wall of thb Tympanic Cavitv.
Of Fenestra ovalis with the stapes ; 6, Fenestra rotunda ; c, Promontory ; d. Muse,
stapedius ; e, OanaUs FallopiaB ; /, Canal for the tensor tympani ; g. Mastoid
process.

Fallopian canal, containing the facial nerve. The Fallopian canal commences
in the internal meatus, above the place where the auditory nerve enters the
labyrinth, passes then into the substance of the petrous bone above the vesti-
bule towards the outer side, and, arrived at the inner wall of the tynipanic
cavity, forms a knee-like bend (Fig. 26), from which the canal continues back-
wards along the inner wall of the tympanic cavity above the fenestra ovalis,
and extends farther along the boundary between the posterior and the interior
walls of the tympanum, with an abrupt bend downwards to the stylo-nxastoid
foramen.

On the portion of the Fallopian canal extending above the fenestra ovalis,
there is an elevation projecting backwards towards the tympanic cavity ; this
is the wall of the horizontal semicircular canal.

At the anterior portion the promontory becomes flatter, and at the same
time narrower, as it is confined between the anterior wall, rising obliquely
towards the ostium tympanicum, and the canal for the tensor tympani. This

Digitized by VjOOQIC

OSSICULA. 27

moBcolar canal commences at the anterior portion of the temporal bone in the
triangular segment, which is formed by the point of the pyramid and the
anterior margin of the squamous portion. It lies (Fig. 26,/) above the
osseous portion of the Eustachian tube, from which it is usually incompletely,
but often completely, separated by a thin, osseous Icmiella. The canal in the
tympanic cavity lies on the border between the interior and superior waUs,
and at the level of the middle portion of the Fallopian canal, in front of and

..d

Fio. 27.— BfALUEUS. Fio. 28.— Ikous. Fio. 29.— Stapes.

a, Head ; 6, Neck ; c, a, Body ; 6, Short pro- a, Head ; 6, Orus ; c.

Handle ; d, Long pro- oeat ; c. Long process ; Foot-plate.

ce«8 ; e, Articular sur- d, Artioolar surfaoe ; e,

face. Inferior toothed process.

above the fenestra ovalis, ending in a spoon-shaped process, which is pointed
outwards {proc. cochlea/ri»)f and above which the tendon of the tensor tym-
pani passes across the tympanic cavity to the handle of the malleus (Fig. 80).

g. Ossicula.

The ossicula form an articulated chain, which extends from the membrana
tympani (Fig. 80) through the tympanic cavity to the fenestra ovalis. They
serve for the conduction of the waves of sound from the membrana tympani
to the labyrinth. On the first of these, the Malleus (Fig. 27), which is
club-shaped, may be observed the oval head (a) with its articular surface
directed backwards (0), the constricted neck (5), the pointed handle connected
with the membrana tympani (c), the long process inserted into the Glaserian
fissure (d), and the short process directed towards the external meatus
(Fig. 80, o). The Incus (Fig. 28), the body of which (a) resembles the crown
of a molar tooth, on the anterior surface of which is the articulation with the
hammer, has two processes, the short (6), whidi points backwards towards
the entrance into the mastoid process, and the long (c), which, slightly bent
in a direction almost parallel with the handle of the malleus, points down-
wards and backwards. On the long process (c) there is the processus lenti-
cularis {osaiouUlm lenUculcure Sylvii), which unites the long process of the
incus to the capitulum of the stapes. The third ossiculum, the Stapes
(Fig. 29), shows many varieties of form. On its capitulum (a) a hollowed
articular surface for the reception of the lenticular process will be seen.
The two crune are arched outwardly, and near their junction with the
head are very much diminished in size (collum staped.). The foremost is
generally a little shorter than the other. They are inserted near the under
surface of the foot-plate, which is convex towards the vestibulum, and cor-
responds in size to the fenestra ovalis. According to the variation in size of
the fenestra, the length of the foot-plate varies from 8-8*5 mm., its breadth

Digitized by VjOOQIC

OSSIGULA.

l'5-2 mm. The average weight, as given by Eitelberg, of the hammer is
0,028, the incus 0,25, and the stapes 0,002.

The longitudinal axis of the malleus is not straight, the head being bent to
the handle at an obtuse angle. The neck of the malleus extends on the
inside to the broad rhomboidal surface of the handle. On the external sur-
face of the neck a ledge, wound in spiral form, will be seen, from which the
strong check-band of the malleus extends to the outer wall of the tympanic
<?avity.

On the border between the neck and handle, and from the foremost angle
of the interior rhomboidal surface of the bone, the long process 6i the malleus
commences as a small, flattened, and slightly bent, flexible, c^eeous lamella,
which lies in the Glaserian fissure, and is easily seen only in the "new-bom

Fl6. 30.— VBUraOAL SlOTION OK THB EXTSBMAL MXATUB, MXMBRAJIA Tt1IPAIII« J^D

Ttmfanio Cavity.

a, Cellular spaces in the saperior wall of the maatai connected with the middle lear ;
6, Roof of the tympanic cavity ; c. Inferior wall ; d. Tympanic cavity ; t, Mem-
brana tympani ; /, Head of the malleus ; g, Handle of tbe malleas ; h, Inm» ;
i, Stapes ; t, FaJlopian canal ; I, Fona jogulariB ; flw, Apertures d glands in the
external meatus. (Bight ear.)

infant. In the adult this process has partially disappeared, and is replaced
by a tight ligamentous band, extending from the Glaserian fissure to the
malleus.

The handle of the malleus is an angular spiculum of bone. The upper-
most part develops outwards into a pointed tubercle of considerable size
{short process of the malleus), on the extremity of which is visible, in the
macerated preparation, a small rough depression, which is the position of the
cartilaginous short process. From the short process the exterior edge of the
handle, firmly connected with the membrana tympani, extends backwards
and downwards, and merges into its spade-like termination. The internal
edge of the handle is developed from the interior rhomboidal surface of the
handle. Between the external and internal edges of the handle there are two

Digitized by VjOOQIC

ABTIGULATION OF THE OSSIOULA. 29

sarfaces elevated above the level of the membrana tjmpani, of which the one
points forwards and inwards, and the other backwards and outwards.

In the embryonic condition the malleus is cartilaginous, and not only in
the new-bom infant will the central pajrt be found still unossified (Moos), but
even in the adult cartilaginous cells will be observed (Heinrich MUller,
LeiUchr. f. Wiasenschaft Zoologies 1858). The greater part of the short
process consists of hyaline cartilage, and is to be considered as the unossiiied
remnant of the embryonic cartilaginous malleus. The assertion of Gruber,
however, that the short process of the malleus has a cartilaginous covering,
which is articulated with a corresponding cartilaginous surface on the mem-
brana tympani, covered by an epithelium, has been proved to be erroneous.

h. Articulation of the Ossicula.

1. ArtictUaHon of MaUeus a/nd Incu9, — On the posterior surface of the
head of the malleus there is an oblong, articular surface, which extends in
spiral form from above downwards and inwards to the boundary of the neck.

Fig. 81. — Siction or thb Abtioulation or Malleus and Inods.

a, Malleus ; 6, Incus ; c, Capeolar ligament with the wedge-shaped meniscus.
(Prepared with hyper-osmic acid. )

It consiBts id two surfaces, which meet in an almost vertical edge. The
imder portion of the head of the hammer is described by Helmholtz as the
* cog ' of the hammer. Corresponding with this, the incus possesses an
articular surface, composed of two parts ; its superior portion (Fig. 28, d) is
directed inwards, its inferior (e) outwards. These articular surfaces are
covered by a thin layer of hyaline cartilage. The articulation of the two
ossicula is effected by a capsular Hgament, which is fastened to the some-
what depressed margins of the artictdar surfaces, and permits of considerable
mobility of the bones. From the inner wall of the capsule a fold, first
described by Pappenheim {Specielle Gewebelehre des Gehororgans^ 1840),
and recently confirmed by Biidinger, projects in the form of a wedge-shaped
meniscus into the cavity of the joint (Fig. 81).

The mechanism of the articulation of the malleus and incus is compared
by Helmholtz to the check-contrivance inside the key usually supplied with
Geneva watches. With the motion of the handle of the malleus inwards, the
inferior • cog ' of the maUeus (Fig. 27, e) catches the inferior cog of the incus

Digitized by VjOOQIC

ARTICULATION OF THE 08BICULA.

(Fig. 28, c), causing the long process of the incus to follow the motion of the
handle of the malleus inwards. On the other hand, with the motion of the
handle of the malleus outwards, a strong movement of the articular surfaces
will follow, the inferior cog of the malleus will recede from that of the incus,
the incus will therefore follow only to a slight degree the motion of the
malleus outwards.

2. Articulation of Incut and Stapes, — ^This joint is formed by the convex,
globular surface of the processus lenticularis of the long process of the iiicus,
and by the correspondingly concave articular surface of the capitulmn of the
stapes. The mode of union of the articular surfaces, which are covered with
hyaline cartilacre, does not admit of much separation of the bones from each

o c If c'

a k fj m

Fig. 32.— Miction thbougu the Incudo-stapedial Articulation.

a. Terminal piece of the long cms of the incas, and connected with it by fibrous
tissue ; o, OssicuL lentic. Sylvii ; «^ Oapitulum stapedis ; g, Articular fossa with
the meniscus ; c, c', Hyaline cartilage covering of the articular surfaoes ; k, k\
Articular capsule ; m. Tendon of the muse, stapedis.

other, but allows them to move sideways to a greater extent. The capsular
ligament, which tmites the articular extremities, is composed of numerous
elastic fibres. According to Btidinger it is also provided with a meniscus.

3. Stapedio -vestibular Articulation. — The tissue connecting the margin of
the fenestra ovalis with the margin of the foot-plate of the stapes, consists of
elastic fibres, which extend in a radiating direction, converging towards the
margin of the foot-plate. This ligament, not equally broad at all parts, is
composed of a layer of periosteum of the osseous portion bordering the
fenestra ovalis, and takes upon itself the functions of the periosteum from
the place where the foot-plate of the stapes is situated. As Toynbee and
Magnus have already proved, the margin of the foot-plate of the stapes, as
well as that of the fenestra ovalis, are covered with a thin layer of carti-

Digitized by VjOOQIC

LIGAMENTS OF THE 08SICULA. 81

laginous tissue, which, according to Eisell, lines the vestibular surface of the
stapes, and encloses in the shape of a heel the margin of the foot-plate.
From Gradenigo*s investigations the inner portion of the foot-plate to the stapes

c
Fio. 33. — SicnoN op the Stapbdio- Vestibular Articulation.

a, Margin of the fenestra ovalis covered with a cartilaginons layer ; b, Margin of the
foot-plate of the stapes covered with a cartilaginous layer ; c, c, Section of the
ligaxnent orbic stapedis.

is developed &om the capsule of the labyrinth, while the outer part cohich
from a ring-shaped deposit at the side of the capsule.

^. Ligaments of the Ossicula.

Besides the above-described capsular ligaments, which connect the articular
extremities of the ossicula, there are also to be enumerated some ligamentous
ties between the walls of the tympanic cavity and the ossicula, which hold
the latter in their position, and act as check-bands in case of too great excur-
sion of these bones. 1. The superior ligament of the malleusj a rounded
band, which extends from the superior exterior wall of the tympanic cavit\-
to the head of the malleus ; it prevents the handle of the malleus from being
turned too much outwards. 2. The a/nterior ligament of tlie maUeti^ (Fig.
84, la). According to Helmholtz it is a short and very broad fibrous liga-
ment, which, encircling the stimap of the long process of the malleus, is
inserted into the parts of the head and neck of the malleus which are directed
forwards. It should be regarded as the residuum of the embryonal process.
Mecklii. The investigations of Sapolini and Verga go to prove this, as they
describe a ligamentum malleo-maxillare, which extends from the malleus
through the Glaserian fissure to the lower jaw. 8. External ligainent of the
malletu (Helmholtz) (Fig. 84, le). This forms, according to Prussak, the
upper boundary of the so-called superior pouch of the membrana tympani.
and is stretched out between the crista capitis mallei and the exterior wall of
the tympanic cavity. It is also useful in preventing the handle of the malleus
from being turned too much outwards. Helmholtz calls the posterior strands
of this ligament the posterior ligaments of the malleus. A line passing
through the latter, if prolonged through the malleus, would intersect the
middle fibrous prolongations of the anterior ligament, and as the axis on

Digitized by VjOOQIC

LIGAMENTS OF THE 088ICULA.

wliich the malleuB turns passes through these two fibrous prolongations,
Hebnholtz calls them the ligaments of the axis of the malleus. 4. Posierior
ligament of the inctia (Fig. 85, 6, b'). The short process of the incus, covered
with a thin layer of fibrous cartilage, leans on the saddle>shaped depression
of the posterior wall of the tympanic cavity, at the entrance to the mastoid
process. Of the fibrous prolongations, which connect the short process with
the osseous wall, the fibrous bundle extending between the short process and
tlie exterior wall of the fissure is especially strongly developed.

The attic or cupola of the tympanum is divided by the articulation of the
malleus and incus into two parts. The one lying between the articulation
and the external wall was described by me as the external attic. This is
formed above by the Ugamentum mallei superior and the fold of the incus,

Fio. 84.— Ligament. Mallki Antib. it

EXTKBN.

6, Head of the mallfms ; la, Lif^^ament.
mallei anter. ; U, Ligament, mallei
extern. ; A, Its partwior portion ; k,
OaseouB tip of the spina tympan. post,
(major), projecting between the liga-
ment, mall. ant. et extern. ; a, Antrum
mast. After a preparation in my col-
lectioB. (Right ear.)

Fio. 35.— LiGAMSNTonB Appabatus or

THB IkfALLEUS AND InCUS.

h. Head of the malleus ; /, Ligament
mall. ant. ; e, Ligament, mall. ext. ; /,
Outer fold of the incus ; 5, inner, b\
outer portion of the ligament, incud.
post.; t. Tendon of the muse tens,
tymp. ; «l, Incudo-stapedial oonnee-
tion; an, Antr. mast. After a pre-
paration in my collection.

ill which occasionally there are several openings (Fig. 85), and appears to a
certain degree separated from the inner portion. The outer attic is divided
into an upper (Fig. 86, m, h) and a lower (r). The latter is known as Prussak*s
space, and is bounded internally by the neck of the malleus, beneath by the
short process of the hammer {k), externally by the membrana Shrapnelli, and
above by the ligament, mall. ext. and the system of cavities first described by
me (TF. med. Wochenschri/t, 16, 1870). These cavities are formed by a
number of inconstant folds and bridges of mucous membrane, which are
stretched between the malleo-incudal articulation to the opposite wall of the
niche. Frussak's space communicates on one side with the upper part of the
attic, on the other with the posterior pocket of the membrana tympani, and
opens into the tympanum at the posterior part by a small round or slit-like

Digitized by VjOOQIC

INTRA-TYMPANIC MUSCLES.

opening, which is hidden by the incus. The external attic, the anatomical
relations of which will be made clear by the accompanying cut (Fig. 87), is
occasionally the seat of a protracted suppuration, with perforation of Shrap-
nell's membrane.

ft. Intra- tympanic Muscles.

The tensor tympani arises in front of the anterior orifice of the canalia pro
tens, tymp, on the osseous wall of the pyramid adjacent to the carotid canal,
and from the cartilaginous Eustachian tube. The roimded tendon of this
penniform muscle leaves the canal at the rostrum cochleare, extends in a
direction almost at right angles to the belly of the muscle across the t^-mpanic
cavity (Fig. 88), and is inserted on the inner margin of the handle of the

Fig. 36. —System of Cavities betwbkn
THE Membrana Tympani and the
Neck of the Malleus.

Fig. 87.— Prussak's Space, Section
through the Tympanic Membrane,
Malleus, Upper and Outer Tym-
panic Wall of a Decalcified Pre-
paration.

Uf Ligament, mall, super ; ^e, Ligament,
mall, ext ; «, Membrana Sbrspnelli ;
0, PniBsak's space ; r, Sjstem of
cavities between the body of the
malleus and incus and the external
tympanic wall ; t, Tendon of the muse,
tens. tymp. After a preparation in my
collection.

malleus, at the anterior edge of the rhomboidal surface, in an oblique direction
to the longitudinal axis of the malleus.

The tendon of the muse. tens, tymp., which can be followed some distance
into the canal, Ues in its free course in a sheath (To^oibee's tensor Hgament).
Henle found this sheath connected with the tendon by considerable pro-
longations of connective tissue. Sometimes, but by no means constantly,
the anterior portion of the tensor tympani is connected with the tensor veli
palatini, either immediately or by tendinous tissue (L. Meyer).

Digitized by VjOOQIC

INTRA-TYMPANIC MUSCLES.

The stapedius muscle has its origin in the eminentia pyramidalis (Fig.
89), situated on the posterior wall of the tympanic cavity. This muscle
appears in longitudinal sections generally pyrifomi, in transverse sections
generally trilateral or prismatic, and with rounded angles. The bundles, arising
from the muscular rfieath, extend from the floor and the lateral walls of
the cavity upwards and towards the middle of the muscle, and merge into
the tendon of the stapedius, the tissue of which can often be traced beyond
the middle of the muscle. This thin tendon passes through the aperture
situated at the point of the eminentia pyramidalis, and is inserted into a
point between the capitulum and the posterior axis of the stapes. The
external fibres of the tendon (Fig. 32) proceed to the capsular ligament and

Fio. 38.— View op the Tympanic Cavitt
AFTEB Removal of the Teg men Ttmp.

hay Malleo-incudal articulation ; t, Muse,
tens. tymp. ; «, Tendon of the muse,
tens. tjmp. passing across the tym-
panum ; /, Nerv. facialis ; g, Genu
nervi facialis ; n, Nerv. petros. superf.
major ; a, Nerv. acusticus ; an. An-
trum mast. After a preparation in
my collection. (Right ear. )

Fig. 89. — Postebior Portion of the
Inner Ttmpanio Wall.

8t, Stapes ; C8, Capitulum stapedis ; m«,
Muse, stapedius in the oavitas stapedii,
with its tendon inserted at the capi-
tulum ; p, Promontory ; /, Nervus
facialis ; v, Vestibule laid open. After
a preparation in my collection. En-
larged to double its size. (Right ear.)

the ossiculum lenticulare. Zuckerkandl states that adipose tissue is found
between the muscle bundles of the tensor and the stapedius.

In the new-bom infant there is found an immediate conununication be-
tween the inferior portion of the muscular cavity and the facial canal ; in
adults either one or more oblong fissvures between the eminentia stapedii and
the canalis facialis will be found. The nerve of the stapedius passes either
through one of these fissures, or through a separate small apertiu*e, on its way
from the facial nerve to the muscle.

It being a disputed point whether the motor elements of the nerve from
the otic ganglion to the tensor tympani belong to the facial nerve (Longet) or
to the trigeminus (Luschka), I determined to investigate the question experi-
mentally in Prof. Ludwig's laboratory.* These experiments were conducted

* Compare the complete account of these experiments as given in the report of the
Wiener Academie der Wissenschaften vom 14 Marz, 1861.

Digitized by VjOOQIC

LINING MEMBRANE OF THE TYMPANIC CAVITY. 35

on the heads of dogs which had just been killed, and gave the following
results :

1. That the tensor tjmpani is supplied by the motor portion of the fifth
nerve.

2. That the central fibres of the stapedius muscle are under the control of
the facial nerve.

I. Lining Membrane of the Tympanic Cavity,

The lining membrane of the tympanic cavity in the adtdt appears as a thin
transparent peUicle, which in some parts is connected closely with the osseous
walls, in others is more easily detached from them. The epithehum of the

— b

Tig. 40.— Section of the Lining Membrane of the Anterior Wall of the

Tympanic Cavitt.

(Decalcified and prepared with oamic acid.)

<t, Epitheliam ; 6, Section of a bloodvessel in the stratum of connective tissne, from
which a branch penetrates into the funnel-shaped depressions of the bone ; c, Blood>
vessel on the surface, penetrating into the bone ; d, d^ Osseous wall ; e, e, Funnel-
shaped depressions in the bone, into which the stratum of connective tissue of the
lining membrane penetrates ; /, Section of a large nervous stem in the stratum of
connective tissue of the lining membrane.

lining membrane in the inferior portion of the tympanic cavity is ciliated and
cylindrical, but in passing upwards it graduaUy changes into the ciliated
pavement variety.

The stratum of connective tissue of the lining membrane of the tympanic
cavity (Fig. 40), in which the bloodvessels, lymphatic vessels, and nerves
ramify, is composed of two layers, of which the inferior must be considered
as the periosteum of the osseous wall. At certain places, especially at the
ridgy inferior and anterior wall, I found (A, /. 0., vol. v.), in the upper layer
of the connective-tissue stratum, networks of fibres similar to the framework
of the membrana tympani.

Digitized by VjOOQ IC

LINING MEMBRANE OP THE TYMPANIC CAVITY.

The lining membrane of the tympanic cavity is an immediate continuation
of the mncous membrane of the pharynx and of the Eustachian tube. In a
considerable number of the ears which I have examined, there were glandular
elements only in the anterior part of the tympanic cavity, in the region of
the tube, and occasionally upon the promontory. These are not constant,
and are never found in the posterior part of the caviun tympani or mastoid
cells.

Vascular folds of mucous membrane extend from the walls of the tympanic
cavity to the ossicula, which thus receive a covering from the lining mem-
brane of that cavity. The most prominent of these folds are the following :
a membrane extending from the superior exterior waJl to the head of the
malleus and to the superior margin of the body of the incus, also a fold (not
constant) passing from the incus to the inner waJl of the tympanic cavity ;
one from the crista transversa to the tendon of the tensor, and a duplicatiu-e
from this to the anterior pocket of the membrana tympani ; and lastly the

Fig. 41. — Oval Body in the Middle Ear.
a. Entrance of the stalk ; 6, Exit of the stalk ; c. Constricted part of the body.

fold of the stapes, which is spread between the crura of the stapes (lig.
obturat. stapedis) and over the posterior crus and the tendon of the stapedius.
There is an inconstant membranous framework, which I first discovered as
extending from the head of the malleus and body of the incus and the
outer attic to the mastoid antrum. Purulent inflammation in the external
attic can extend to the mastoid antrum by means of this framework, and
the opposite may occur from the mastoid antnmi to the attic and Prussak's
space.

Besides the above-named folds of mucous membrane, I found in the tjan-
panic cavity a number of inconstant prolongations of connective tissue, which
have formerly been considered as pathological products, but which I was the
first to prove to be {Beleuchtimgabilder des Trommel/ells, 1865) a residuum
of the gelatinous connective tissue which fills the middle ear in the fcetal
state. Such bridges and strings often occur between the membrana tympani
and inner wall of the tympamnm, and between the handle of the malleus,
long process of the incus, and stapes. Almost always there are string- or
band-shaped attachments between the crura of the stapes and walls of the
pelvis ovalis, which favour the formation of adhesions in inflammatory pro-
sesses. Upon these connective tissue structures I discovered with the micro-
scope peculiar formations, previously unknown. These formations (Fig. 41)
are usually oval, sometimes a little constricted in one or more places (c),
pyriform, and in rarer cases triangular ; occasionally both these shapes are
combined in one specimen. These small bodies are covered with epitheHum,

Digitized by VjOOQIC

UNXNG MEMBRANE OP THE TYMPANIC CAVITY. 37

and have, superficially as well as in section, a fibrous structure, arranged
in layers parallel with the exterior outline. Between the layers, spindle-
shaped bodies are to be seen.

A fibrous stalk (a) of varying size arises with a broad base from the mem-
branous surface below, enters into the rounded extremity of this body, and
traversing it, issues at the other extremity and is inserted into a membrane
or into the osseous wall opposite. Sometimes one stalk traverses several of
these bodies, or is divided into two stalks when issuing. The size of these
bodies varies between 0*1-0*9 mm. and upwards. These bodies I found mostly
in the posterior portion of the tympanic cavity, in the antrum mastoideum,
also in the upper tympanic space, on the membrana tympani, and in Prussak*s
space. These bodies were first discovered by me {Wien, med. Wochenschri/t,
Kov. 20, 1868), but were later described by Kessel and others.

The lining membrane of the tympanum in the new-bom infant is remarkable
for an abundance of vessels, as also for great tumefaction of the tissue
(Brunner). In places which are perfectly smooth in the adult, for instance
on the promontory, are often found densely packed papill© of the same
structure as those described as occurring on the membrana tympani (p. 26).

Moos succeeded in seeing tufts of bloodvessels in the mucous membrane of
the membrana tympani. The great swelling and vascularity are connected
with the evolutional processes which take place in the middle ear in the foetal
state and after birth. For the foetal tympanic cavity is filled with a gelatinous
mass, which on microscopic examination presents the characters of imde-
veloped connective tissue, spindle-shaped cells in a structureless, gelatinous,
fundamental substance. This tissue, designated by Wendt as a proliferation
of the mucous lining of the wall of the labyrinth, often displays, even before
birth, the appearance of incipient decay, fatty degeneration having already
commenced in the epithelium of the lining membrane of the middle ear and
in this gelatinous tissue. After birth a rapid degeneration of the gelatinous
substance into a yellowish-green, thickish fluid is caused by the entrance of
air into the tympanic cavity. This fluid contains fat and pus corpuscles. As
investigations have shown, in the great majority of new-bom infants there is
found in the tympanic cavity a pus-like substance, which is reabsorbed in
a few weeks after birth by the highly vascular mucous membrane. The
statement that in all these cases a purulent inflammation of the middle ear is
present (Netter) is in no wise proved. The opinion I advanced, that in most
of these cases it was a degenerative process and not a purulent inflammation,
was sustained by the bacteriological investigations of Gradenigo and Fenzo
{Z.f, 0., Bd. 21, S. 298).

m. Vessels and Nerves of the Tympanic Cavity,

The arteries which supply the lining membrane and the structures in the
tympanic cavity spring from various vessels. The anterior and middle por-
tions of the tympanic cavity are supplied (1) by the tympanic artery (from
the external maxillary), which enters the tympanum through the Glaserian
fissure ; (2) by the ascending pharyngeal (from the external carotid), which

Digitized by VjOOQIC

38 VESSELS AND NERVES OF THE TYMPANIC CAVITY.

penetrates the floor of the tympanum, runs over the promontory, and ascend-
ing to the tegmen tympani anastomoses with the middle meningeal ; (8) by
the branches of the ascending pharyngeal artery (from the external carotid) ;
(4) by branches of the middle meningeal artery, which penetrate through the
hiattis cwnalis Fallopice and the fissura petroso-squamosa into the tympanic
cavity, and (5) by the internal carotid, which sends a few small branches
through minute vascular orifices of the carotid canal in the petrous bone into
the tympanic ca\'ity. The stylo-mastoid artery, which penetrates into the
Fallopian canal, supplies the neurilemma of the facial nerve and the stapedius
muscle, and also sends small branches to the lining membrane of the tym-
panic cavity and mastoid cells, and anastomoses, through the apertur. spur,
canalis Fallopii, with the middle meningeal.

The veins of the cavum tympani pass (1) into those of the external
meatus by means of numerous anastomotic branches which perforate the
membrana tympani; (2) into the venous plexus (Kektorzik), which siurounds
the internal carotid in the carotid canal ; (8) into those of the dura mater
through the flssura petrosa-squamosa, and (4) into the venous plexus of the
lower jaw.

According to the investigations made by Prussak on dogs, the arteries often
pass into the veins ^dthout the intervention of capillaries. The veins of the
lining membrane are very tortuous, and show here and there considerable
pouch-like dilatations of their Imnen.

To determine the relation of the bloodvessels of the mucous membrane to
the osseous walls of the tympanic cavity, I imdertook a series of anatomical
examination^,* which led to the result that vascular connections are kept up
between the middle ear and the labjTinth through the osseous wall separating
them.

In microscopic sections of the wall of the labyrinth, prepared with osmic
acid and decalcified, the bloodvessels of the middle ear can be seen proceed-
ing from the deeper layers of the lining membrane, accompanied by numerous
prolongations of connective tissue, penetrating almost perpendicularly into
the funnel-shaped mouths of the canals of the osseous wall (Fig. 40, e, e).
If the inner wall of the tympanic cavity, prepared with osmic acid, is closely
scrutinized, even with the naked eye small black dots will frequently be found
between the ramifications of the nerves and the vessels, which on closer
examination appear as the culminating points of a number of vessels. The
vessels of the osseous wall, then, form a connection on the one hand with
the bloodvessels of the lining membrane of the middle ear, on the other with
the vessels of that of the labj-rinth.

This relation of the lining membrane of the tympanic cavity and its blood-
vessels to the osseous wall is frequently of considerable importance, as there
can be no doubt but that hypersemia and congestion of the vessels of the
middle ear, accompanied with inflammation, owing to these anastomoses,
sometimes extends to the vascular regions of the labjTinth, causing there
• temporary or permanent disturbances of nutrition.

* Ueber Ana9t<ymmen zwhchen den Oefassbezirken des Mittclohrs und des Laly-
rintliB, A,f, 0., vol. xi.

Digitized by VjOOQIC

VESSELS AND NERVES OF THE TYMPANIC CAVITY.

Up to the present but little is known of the lymphatic vessels of the cavum
t^-mpani.

Besides the sensory fibres of the trigeminus, the sympathetic and the glosso-
pharyngeal nerves take part in the supply of the lining membrane of the
middle ear. Of these three, the branch of the latter nerve to the tympanic
cavity is the one most highly developed. From the jugular fossa it enters the
tympanic cavity through an orifice in the inferior wall, and extends upwards
in the groove on the promontory to unite with the nerv. petros. superf.'
minor. In this, called Jacobson*s nerve, Pappenheim, Kolliker, and Krause
(Zeitschrift /. rat. Medicin, 1866, p. 92) have traced ganglion cells inserted
at intervals. W. Krause found a moderately large branch passing from the
tympanic plexus to the cartilaginous Eustachian tube; and I saw several
times such a branch pass directly from Jacobson*s nerve.*

The sympathetic nerves of the lining membrane of the middle ear spring
from the sympathetic plexus, which accompanies the carotid artery in its
canal. By means of orifices in the canal several small branches of this plexus
enter the tympanic cavity as nervi carotico-tymp., to form in its anterior
portion, together with the ramifications of Jacobson's nerve and the n. petros.
superf. minor, the plexus tympanicus. From this proceed the finer nerves
for the whole lining membrane of the middle ear. On the promontory,
especially near the fenestra ovalis, clusters of ganglion cells are inserted in
these nervous bundles. Besides the latter, a dehcately ramifying network of
nerve-fibres is seen, which spreads partly above and partly below the vessels,
and forms ganglionic s^'eUings at places where several fibres meet.

B. The Eustachian Tube.

The Eustachian tube forms the connection between the tympanic
cavity and the pharynx. It is the passage by which an exchange of
air takes place between the external atmosphere and the tympanic
cavity.

The Eustachian tube consists of an osseous and a cartilaginous
portion. Its position is oblique, having, according to Henle, a
direction almost exactly disigonal between the horizontal and the
vertical, the axis of the tube forming an angle of 135' with the
horizontal axis of the meatus, and one of 40" with the horizon.
The tympanal opening of the Eustachian tube is about 2*5 cm.
higher than the pharyngeal opening.

The length of the whole canal can only be determined approximately,
because the commencement of its osseous portion in the tympanic cavity is
not sharply defined ; it amoimts generally to 84-86 mm., of which the carti-
laginous portion forms two-thirds. The narrowest part, the Isthmus tubcBy
which is situated in the cartilaginous section in front of its point of tmion

* Compare BischofiF. jun., Mikroskopische Analyse d^ Anastamosen der Kopf-
ntrven, MUncben, 1865.

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OSSEOUS PORTION OF THE EUSTACHIAN TUBE.

with the osseous portion, measures in the corrosion preparations prepared by
Bezold 3 mm. in height, and not more than ^ nun. in width. Its distance
from the ostium pharyngeum averages 24-26 mm.

a. The Osseotcs Portion of the Eustachian Tube.

The osseous portion of the Eustachian tube, bounded above by the canal of
the tensor tympani, and below and towards the middle by the carotid canal,

Fig. 42.— Eustachian Tdbk and Ttmpanic OAvrrT.

a, Membrana tympani ; &, Head of the malleos ; c, Lower end of the handle of the
malleus ; d. Body of the incus ; e, Short process of the incus ; /, Tensor tympani ;
g. Ostium pharyngeum tubse ; h. Isthmus tubs ; t, Ostium tympanicum tubse.
(Right ear.)

is a prolongation of the anterior portion of the tympanic cavity directed
inwards. The boundary between the tube and the cavity, however, is not a
very marked one, because the superior and lateral waJls of the latter merge
without interruption into the former. On the under-side the boundary is
better defined, especially where the obUquely rising anterior wall of the
tympanic cavity curves towards the inferior wall of the osseous tube (Figs.
42 and 48, oQ. Above this place is situated the ostium tympa/nicum tuba
Euatachii, irregularly defined and inconstant in size ; its height, according
to Bezold, is 4*5 mm., its width 8*8 mm. The lumen of the osseous canal,

Digitized by VjOOQIC

CABTILAGIK0U8 PORTION OP THE EUSTACHIAN TUBE.

the diameter of which, according to Henle, amounts to about 2 mm., becomes
only slightly less towards the place of union with the cartilaginous portion of
the tube, and shows in the transverse section an irregularly trilateral outline.
(L. Mayer.*)

b. The Cartilaginous Portion of the Eustachian Tube.

The cartilaginous portion of the Eustachian tube is attached to the rough,
iiregular, and oblique margin of the anterior extremity of the osseous portion ;
laterally its walls approach nearer to the tympanic cavity than in their inferior
part, because the lateral wall of the osseous part of the tube is shorter than

Pig. 43.— ^Sagittal Section through the Entire Middle Ear op an Adult,

Inner Half.

op, Ost. pharyng. tubs ; te, Canalis tubee Eust. ; ot, Oat. tymp. tubsB ; tp, muse,
tens. tymp. ; p. Promontory ^dth the anastomos. Jacobsonii ; u, Lower wall of the
tympuiic cavity ; st, Stapes ; »p, Masc. stapedius ; /, Facial nerve ; on, Antrum
mastoid. ; to, v/. Mastoid cells. After a preparation in my collection. (Left ear.)

the inferior wall. This part of the tube is not in its whole extent cartilaginous,
the groove-like cartilage being formed into a canal by a membranous plate.

The cartilaginous plate, turned in at its superior margin, forms a narrow
groove near its insertion into the osseous portion, the outer wall of which is
broader than its inner wall ; farther down, however, a few lines distant from
the osseous tube (at the spina angularis, Henle), the height of the inner
cartilaginous wall rapidly increases, while the outer wall along the superior
margin of the cartilaginous plate forms a narrow tumed-in stripe (Fig. 44, b),
which roofs over the Eustachian tube. At a superficial view the cartilage of
the tube appears triangular in shape, its apex resting on the osseous tube,
while its base is prominent as a rounded bulging on the lateral wall of the
pharynx. The portion of the cartilage near the osseous tube is attached to
the basilar fibro-cartilage, and is less movable than the inferior broader
portion standing out from the base of the skull. The cartilage itself, com-
posed on the surface of hyaline, and in the deeper layers of a fibrous f anda-

* Studien fiJer die Analomie des Canalis Eustachii, 1866.

Digitized by VjOOQ IC

CARTILAGINOUS PORTION OP THE EUSTACHIAN TUBE.

mental substance, shows very often a number of irregular fissures, clefts, and
sometimes disruption of the cartilage of the tube into several separate pieces.
Moos and Zuckerkandl describe several accessory cartilages lying in the
region of the cartilago-membranous portion of the tube.

The Eustachian canal in the child differs considerably as regards length,
width, and direction from that in the adult. Its length in the newly-born
measures 18-20 mm., of which 8-9 mm. belong to the osseous, and 11-12 mm.
to the cartilago-membranous portion. Its tympanic orifice is comparatively
large, and lies somewhat lower ; on the other hand, the pharyngeal orifice is
indicated only by a slight depression or fissure, and the posterior prominent

Fig. 44.— Trans verhb Section or thb Cartilaginous Eustachian Tube.

a, Central cartilaginous plate ; b. Cartilaginous hook ; c, Space below the cJBirtilaginous
hook ; d. Base of the Eustachian tube ; e, t\ Folds of mucous membrane ;/, Cylin-
drical epithelium ; g^ Muse, tensor palat. mollis ; /t, Muse, levator palat. mollis.

portion of the tube forms a hardly noticeable projection on the wall of the
pharynx. The tube in the child is also shorter and wider, a condition which
is of practical importance in so far as obstacles in it, caused by the products
of disease, can with greater facility be removed by a current of air.

The relation of the membranous portion to the cartilaginous plate is most
clearly shown by transverse sections of the tube. Examining the anatomical
relations of the cartilaginous tube by this method, v. Troltsch, Moos, Henle,
Biidinger, and L. Mayer have brought to light a number of very interesting
anatomical facts. In such a transverse section (Fig. 44) we see in the first
instance the central cartilaginous plate (a), twisted round like a hook (6) at
its superior margin. At the end of this hook commences the membranous
portion of the tube, delicate and thin near the cartilage, increasing, however,
in thickness downwards, and mostly supported by an abimdant adipose and
glandular layer. The membranous portion, which merges below into the
salpingo-pharyngeal fascia, according to v. Troltsch forms the smaller half of

Digitized by VjOOQIC

LINING MEMBRANE OF THE EUSTACHIAN TUBE. 48

the circmnference of the Eiistachian tube, and constitutes, together with the
cartilaginous hook, the lateral wall of the cartilaginous portion of the tube (i),
and also its base (d). The portion of the membranous tube lying in the
region of the osteum tubaB is much thinner than the upper portion, where it
receives fibrous tissue from the spina angularis of the sphenoid, and also an
accessory cartilage.

By reason of this hook-like twist of the cartilage, a space is formed below
it, the proportions of which vary in the several portions of the Eustachian
tube. In transverse sections of hardened preparations in the superior portions
near the osseous part a small space will be found below the curvature of the
hook, the walls of which do not come into contact with each other. In the
middle portion, however, the central and lateral walls of the tube are com-
pletely in contact, and only near the ostium pharyngeum do the walls again
diverge a little.*

The mucous membrane of the membranous portion of the Eustachian tube
has an abundance of folds in its lower portion. According to Moos, these
folds of the membranous portion form a bulging immediately behind the
ostium pharyngeum, which closes the tube in this place, when at rest. Above,
the abundance of folds graduaUy decreases.

Lining Membrane of the Eustachian Tube, — The walls of the Eustachian
tube are covered by a glandular mucous membrane with a ciUated cylindrical
epithelium. The lining membrane of the osseous tube is smooth and closely
united with the periosteum. The mucous membrane of the cartilaginous
plate is more strongly developed, and a great number of acinous glands dis-
charge on its surface (Fig. 44, t, e). These glands extend to the neighbour-
hood of the perichondrium, but sometimes, especially near the orifice in the
pharynx, they can be traced through fissures in the cartilage of the tube,
into the connective tissue outside the tube. These glandular elements are
most numerous near the orifice of the tube in the pharynx, while in the
osseous portion, especially towards the t^Tupanic cavity, they are much less
abundant. Besides this, Gerlach found in the mucous membrane of the
child sebaceous glands, the walls of which consist of a difiFuse conglomerate
glandular substance, and which occur in great numbers in the whole carti-
laginous portion of the tube. Gerlach proposes to name these sebaceous glands
tonsib of the tube, as they are analogous to the pharyngeal tonsils of Luschka.

Mueclee of the Eustachian Tube, — The liunen of the Eustachian tube, the
walls of which are in contact with each other, sometimes more, sometimes
less intimately, is temporarily opened by a muscular apparatus. This is
principally produced by the levator and tensor palati mollis.

The first of these, the levator palati mollis (petro-ealpingo-staphylvnus),
arises from the surface of the petrous bone next the carotid canal. Its
rounded belly extends parallel to the Eustachian tube, is closely applied
partly to the membranous portion (Fig. 45, Z, ^), which forms the base of the
tube, partly to the cartilaginous plate, and is inserted in a radiating manner
into the soft palate below the orifice of the tube in the pharynx. None of

* Compare v. Trdltsch, Arch. /. Ohrenheilk., vol. ii., and v. Moos, Archiv. f.
Augen. und OhrenheilL, vol. i.

Digitized by VjOOQIC

MUSCLES OF EUSTACHIAN TUBE.

its fibrous bundles arise, as was formerly believed, from the Eustachian tube,
for it is only attached to it by a short band of connective tissue. The action
of the levator palati mollis is not confined to the veliun palati alone, for the
base of the Eustachian tube is raised at every contraction of the muscle, by
which the orifice of the tube is made smaller, but the resistance in the tube
is lessened owing to the shortening and widening of its aperture.

The tens, palat. moll, (apheno-salpingo-staphylintis s, circumflexus palat,)

Fig. 45.— Eostaohian Tube with its Muscles (Natural Size).

kf Cartilaginous plate of the Eustachian tube ; m, Pars membranacea of the
Eustachian tabe ; o«, Ostium pharyng. tubce ; cA, Cboana ; 2, Muse levator palati
mollis ; T, Radiation of the levator in the velum palati ; h. Hamulus pterygoideus ;
tf t, Muse, tensor palati mollis, winding round the hamulus. After a preparation
in my collection. (Right side.)

has its origin at the inferior surface of the sphenoid bone ; a great number of
its bundles, however, come from the short, hook-like part of the lateral carti-
laginous wall (Fig. 45, ty t), and from the membranous part of the cartilaginous
portion of the tube. In its downward course its flat belly lies close to the
lateral wall of the membranous portion of the tube, and is rather firmly

Digitized by VjOOQ IC

MUSCLES OP EUSTACHIAN TUBE. 45

attached to it. The direction of the fibres of the belly, the tendon of which
is coiled round the hamulus pterygoideus, and radiates in the fibrous pro-
longation of the hard palate (Henle), forms an acute angle with the direction
of the cartilaginous portion of the tube. The tendon of the muscle is attached
so tightly to the hamulus pterygoideus, that the effect of the muscular con-
traction is greater in the Eustachian tube than in the soft palate. By the
contraction of this muscle the cartilaginous hook is slightly unfolded, the
membranous portion of the tube is lifted up a little from the cartilaginous
portion, and the lumen of the tube is opened. V. Troltsch, who first drew
attention to the importance of the anatomical relations to the physiological
function of the Eustachian tube, proposes the name * abductor * or * dilatator
tubsB ' instead of the hitherto current tensor palati moUis. There remains
to describe the salpingo-pharyng. muscle, which extends from the palato-
pharyngeus muscle to the prominence at the ostium pharyngeimi.

In connection with the muscles of the Eustachian tube are three fasciae^
which play an important part in the opening of the tube, and which are
partially inserted in it, 1. The fascia salpingo-pharyngeus (v. Troltsch)
which extends from the ridge of the tube to the hamulus pterygoideus, and
separates the tensor from the levator muscle ; 2. The external fascia of the
tensor (Weber-Liel) ; and 8. That fascia which is intimately connected with
the ligam. salpingo-pharyngeiis, and borders on the median surface of the
levator muscle.

The arteries of the Eustachian tube proceed from the ascending pharyngeal
and the middle meningeal. The veins communicate with those of the cavum
tympani and the naso-pharynx, and, anastomosing with the sinus cavemosus,
form a plexus which, when over-filled with blood, changes the calibre of the
tube to a considerable extent.

C. The Mastoid Process.

The mastoid process forms the posterior portion of the middle
ear. The conically-shaped cellular process is wanting in the newly-
born infant, being represented by that nipple-like portion which is
preformed in the embryo. The absolute mastoid process originates
as a small tubercle on the temporal bone of the infant behind the
superior termination of the annulus tympanicus. Partially by its
individual growth, and partially from muscular action in the first
years of life, it grows downward, but does not acquire the typical
shape of the mastoid process of the adult imtil the third year
(Zuckerkandl).

Between the anterior surface of tuberculiun mastoideum and that posterior
portion of the pars squamosum which, according to Toynbee, forms the
anterior wall of the mastoid antrum in the newly-born child, lies the sutura
mastoidea-squamosa. This was described by Dr. Vemey, and generally
disappears during the first years of life, although sometimes persistent in the

Digitized by VjOOQIC

TOPOGRAPHY OF THE MASTOID PBOCESS.

adult as a jagged and deep-seated furrow on the outer surface of the mastoid
process.

The mastoid antrum, the only one of the pneumatic spaces present in the
newly-born child, is a longish cavity, 5 mm. in width, situated behind, and
higher than the cavum tympani. According to Zuckerkandl, the develop-
ment of the cellular spaces in the mastoid process takes place in the follow-
ing manner : The cellular proliferation commences at the upper posterior
periphery of the mastoid antrum, and then proceeds towards the outer
lamella. According to Schwartze and Eysell, the mastoid cells are arranged
during their development in a typically radiar manner .towards the mastoid
antrum, but this arrangement is seldom recognisable in the adult, because
of the formation of new osseous septa and the disappearance of others already
developed.

The complete mastoid process is divided by anatomists into two portions :
the horizontal portion or mastoid antrum is a large, somewhat lengthy

Fig. 46.

irregular space, situated below the tegmen mast., and reached through the
triangular orifice in the posterior wall of the tympanic cavity ; the vertical
portion has cellular spaces which communicate with the antrum.

Both the size and shape of the mastoid process present many variations.
In some cases it is massively developed, in others it is reduced to a short
solid protuberance. Considerable differences are also found in the contents
of the process, which may be composed, not of pneumatic spaces, but of
a spongy, fatty, or compact osseous substance. Zuckerkandl found that of
250 temporal bones examined by him in only 86*8 per cent, did the mastoid
process contain pneumatic spaces alone. In 48*2 per cent, it was partially
diploetic, and partially pneumatic, and in 20 per cent, it was entirely fatty,
diploetic or sclerosed.

We therefore dififerentiate three principal types of the mastoid process : the
pneumatic, the diploetic, and the combination of the two or mixed form. The
pneumatic mastoid process is often composed of a large nimaber of irregular
cellular spaces, penetrating the temporal bone in all directions and covered
by a thin external osseous lamella (Fig. 46). In other cases the whole process
consists of one or two large cavities, or of numerous small cavities, together

Digitized by VjOOQIC

TOPOGRAPHY OF THE MASTOID PROCESS.

with one or more larger ones, which, either at the apex or inner side, give
a dome-shape to the roof. Frequently large cavities communicate with the
antrum by a narrow canal only.
A satisfactory idea of the position of the mastoid cells in the temporal bone

Fig. 47»— Cobbosion Cast of the Middle Eab (afteb Bezold).
o, Oitteum pharyng. tubsB ; t, Isthmus tub® ; ot, Osteum tymp. tubse ; u, Lower
portion of the cavum tympani ; ^, Membrana tympani with the depression for the
malleus and umbo ; A, Cavity for the malleus and incus ; a, Posterior end of the
mastoid antrum ; e, Intercellular space ; te, Terminal space.

can only be obtained by means of corrosion preparations. The same remark
appUes to the topography of the organ of hearing. On this subject we are
greatly indebted to Fried. Bezold, whose masterly work. Die Corrosions-
a/natomie des Ohrea, Munchen, 1882, cannot be too highly recommended.

The pneumatic cellular cavities starting from the mastoid antrum extend
backwards to the sutura occipitalis, smrounding the transverse sinus and the
emissarium santorin ; downwards to the apex and inner surface of the

mastoid process; upwards and forwards
to the linea temporalis and the root of the
zygomatic process, thereby completely
encircling the auditory meatus, with the
exception of the lower anterior wall, and
extending inwards frequently to the apex
of the pjTamid. The cellular cavities
often siuTound the labjTinth on all sides,
and directly adjoin the bulbus vena
jugularis and the posterior portion of the
carotid.

The diploetic mastoid process shows on
section a marked difference in appearance,
consistmg, from its apex (Fig. 48, c) to the upper border (6), of small-celled
diploe and osseous tissue, rich in fatty substances, and only occasionally pre-
senting air cells in the vicinity of the mastoid antrum, which is, as a rule,
smalL The sclerosed process is seldom compact, generally containing either

FiQ. 48.

Digitized by VjOOQIC

TOPOGRAPHY OP THE MASTOID PROCESS.

very close diploetic tissue or large single gaps. The diploetic and sclerotic
processes are on an average smaller than the pneumatic.

The third type is represented by the partially diploetic, partially pneumatic
form. Here we have numerous varieties, two of which are most frequently

Fig. 49.

Fia. 50.

met with, viz., that in which the lower portion of the mastoid process is
diploetic and the upper pneumatic (Fig. 49), and that in which the lower and
posterior portion (Fig. 50, d, ^) are diploetic, the anterior portion {d, p) con-
taining pneumatic cells.
The pneumatic spaces of the mastoid process are lined with a delicate

'J h

Fig. 51.— Vertical Suction of the Mastoid
Process and the Osseous Meatus,

a, Mastoid cells ; 6, Posterior wall of the osseous
meatus ; c, Anterior wall of the osseous meatus.

Fig. 52. — Horizontal Section
OP the External Meatus
AND THE Tympanic Cavity.

a, Anterior wall of the meatus ;
6, Posterior ; c, Cells of the
mastoid process ; dy Meatus ;
0, Membrana tympani ; /,
Tympanic cavity ; ^, Fossa
sigmoidea. (Right ear. )

membrane, which is a continuation of the mucous membrane of the tympanic
cavity, is closely united to the periosteum and has a layer of non-ciliated
epithelium. In the antrum are often found membranes and branch-like bands

Digitized by VjOOQIC

TOPOGRAPHY OF THE MASTOID PROCESS.

of connective tissue, on which are the pedunculated bodies discovered by me
and described on page 86 (Fig. 41).

The cellular spaces of the mastoid process are bounded in front by the
posterior end of the pyramid, the tympanic ca^'ity, and the posterior wall of
the osseous meatus, as shown in the accompanying figures (Figs. 50 and 51).
The outer wall is formed by that convex osseous plate which can be felt
behind the auricle, and which varies very much in extent of siurface and
thickness (4 to 10 mm.). Where the mastoid process joins the posterior wall
of the meatus, i,e,, on the posterior superior orifice of the latter, there is
found, though not invariably, a pointed eminence, varying in development,
and called the spina supra meatum. It serves as an anatomical landmark in
operations on the mastoid process.

Posteriorly the mastoid process is contiguous to the occipital bone, in which

w uf g i

Fig. 53.— Horizontal Siction thbouoh the Pneumatic Mastoid Prooess.

j7, Posterior wall of the meatus ; ^, Cavum tympani : a, Mastoid antrum ; «, Sigmoid
ainni ; ir, tcr'. Basis for operation on the external covering of the mastoid prooess.

one occasionally finds cellular spaces communicating with the mastoid cells
(pneumatic occipital bones, Hyrtl). The upper wall of the mastoid process
which faces the cranial cavity is called the tegmen mastoideum, and is formed
by the posterior continuation of the tegmen tympani and the inner lamella of
the horizontal part of the squamous portion of the temporal bone.

The inner boundary of the mastoid process is made up of two parts, a
lower and an upper. To the lower belongs the conical portion of the process,
in which a groove is cut (incisura mastoidea), running in a sagittal direction,
and intended for the insertion oi the digastric muscle. The osseous wall on
tliis side is frequently as thin as paper, so that abscesses can find an outlet
in this direction (Bezold). The upper portion of the inner boimdary is espe-
cially interesting, as it is traversed by the winding course of the sigmoid
sinus, which originates at the eminentia cruciata interna of the occipital
bone, passes over the inner surface of the mastoid process, and arriving at

Digitized by VjOOQIC

TOPOGRAPHY OP THE MASTOID PBOOESS.

the foramen jngalare (lacerum posticum), rises with an abrupt curvatiu'e
against the inferior wall of the pyramid, where it forms the bulbus venie
jugularis. Suppurative inflammation of the mastoid process, which also
attacks its inner wall, may consequently bring about fatal phlebitis of the
sinus.

The anatomical varieties in respect to the relative position of the sigmoid
sinus to the mastoid process, and the posterior wall of the meatus, are of
great practical importance. Bezold and Hartmann have called attention to
the fact that the sigmoid sinus is occasionally shifted anteriorly and laterally,
so that injury to the same is not easily avoidable in operations of opening
the mastoid process. In more than 500 temporal bones which I examined,
I found the position of the sinus most favourable when the mastoid process
was strongly developed, and entirely filled with pneumatic spaces. In these

Fig. 55. — Horizontal Sbotion thbouoh a
Compact MASTom Process, ooNTAiNiNa

A SMALL AMOUNT OF DlPLOlL

tj Cavum tympani ; tt. Under wall of
meatus ; «, Sigmoid sinus ; to. Posterior
boundary of buis for operation.

g vj

Fig. 64. — Horizontal
through a mastoid

PARTLY DiPLOfinO, PARTLY PNEU-
MATIC.

j7, Posterior wall of meatus; a,
Mastoid antrum ; 8, Sigmoid sinus ;
117, u;'. Basis for operation.

«ase8 (Fig. 52) there is a broad space between the sigmoid sinus and the
posterior wall of the meatus (^), which in operating permits access to the
Antrum without danger of wounding the sinus. I found the relations to be
less favourable in the diploetic and compact mastoid processes. Here the
spaces between the sinus and the posterior wall of the meatus is mucli
narrower (Fig. 54), and in some cases the sinus is shifted so far forwards and
outwards as to leave only a small connecting bridge (Fig. 55), with the result
that in operating exposure of the sinus is rendered unavoidable.

An abnormally oblique position of the middle cranial fossa produces scarcely
Any hindrance to the present methods of opening the mastoid process.

The spaces within the mastoid process are supplied by branches of the
middle meningeal and stylo-mastoid arteries. The external surface by the
post-auricular artery. The external veins are connected partly with the veins
on the side of the neck which empty into the jugular, partly with the emissar-

Digitized by VjOOQIC

TOPOGEAPHY OP THE SOUND-CONDUCTING APPABATUS. 51

Santorini conung from the cavity of the skull through the pars mastoideum.
The veins from the mast, antrum and cells partly anastomose with those of
the cavum tympanima and the corticolis partly empty into the emissar-
Santorini, and through small canals in the inner wall of the mastoid process
into the sigmoid sinus. Besides these is a vascular canal passing from the
inner part of the mastoid process beneath the superior semicircular canal,
through the fossa subarenata into the cavity of the skull. This is in imme-
diate connection with the diploetic spaces of the mastoid process. The
nerves of the mast, antrum and cells come from the tympanic plexus, those
of the external surface from the n. auricularis magnus.

D. TOPOGBAPHY OP THE SoUND- CONDUCTING ApPABATUS.

The topography of the auricle is best studied by means of horizontal and
vertical sections made from preparations hardened in alcohol. In such
preparations the greater portion of the cartilage of the ear will be seen to
stand away from the lateral surface of the skull, whereas that portion which
surrounds the external opening applies itself to a varying extent to the
squamous portion of the temporal bone and the mastoid process. That
portion of the auricle which lies above the external auditory orifice, the radix
helicis, the anterior superior segment of the concha, and the anterior portion
of the fossa intercruralis, is attached to that surface of the horizontal portion
of the pars squamosa which proceeds to the squama of the temporal bone,
and is crossed by the linea temporahs. The middle segment of the concha,
lying behind the external auditory orifice, is attached to the mastoid process
to the extent of 1^ to 2 cm. by means of flexible connective tissue. This fact
is of importance in so far that this segment of the auricle partially covers
that surface of the mastoid process which is used for operating upon, and
consequently the auricle must be detached from that portion. That segment
of the cartilage of the ear which forms the tragus, and which Ues in front of
the ext. auditory orifice, is contiguous on its inner aspect to the cartilaginous
meatus and the external side of the glenoid fossa.

The cartilaginous meatus is partially enclosed in the osseous meatus. The
superior wall of the osseous meatus completely roofs in the cartilaginous
portion of the cartilaginous meatus as far as the external orifice of the ear,
and in a similar manner the cartilaginous portion is covered in by that outer
portion of the posterior wall which is formed by the mastoid process. Con-
sequently, by inserting the finger into the cartilaginous meatus, one is able
to feel the superior posterior wall of the osseous meatus directly behind the
external orifice. Of the lower and longest wall of the cartilaginous meatus,
the external portion alone is palpable, the inner portion being covered by the
parotid gland. The anterior cartilaginous wall is in its inferior portion con-
tiguous to the posterior surface of the capsule of the maxillary joint, the
excursions of which are communicated to the wall of the meatus.

The superior boundary of the osseous meatus is formed by the middle
cranial fossa, the posterior by the cells of the mastoid process and the
anterior by the maxillary joint, the cavity of which lies higher than the

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TOPOGRAPHY OP THE SOUND-CONDUCTING APPABATUS.

lumen of the osseous meatus. The space occupied by the cavity of the joint
extends farther out than the osseous meatus.

A thorough knowledge of the topographical relation of the membrana
tympani to the inner wall of the tympanic cavity is of great importance to
the practitioner, for the proper understanding of pathological changes in the
different portions of the tympanic cavity, as well as on account of operation
in that cavity and on the membrana tympani. To render the relations of
the membrana tympani to the various portions of the inner wall of the cavity
more distinct, we divide the outer surface of the membrana tympani (Fig. 56)
into four segments, the axis of the handle of the malleus being produced
downward and intersected by a horizontal line drawn at a tangent to the

lower end of the handle. The pro-
jection of the wall of the tympanic
cavity with respect to the membrana
tympani given by Zuckerkandl * agrees
well with the anatomical preparations,
but is considerably modified by the
inclination of the membrana tympani
to the horizontal met with in practice.
In the normal position of the head, in
which otological experiments are made,
we find that :

(1) The anterior superior segment (a)
of the inner wall of tlie cavity, which
lies next to the ostium tymp. tubse,
corresponds to the anterior superior

Fig. 56. — Pbojection of thb inneb
Wall of thb Tympanic Cavity

WITH BISPBOT TO THB MeMBBANA

Tympani.

a, Ant. sup. quadrant of membrana
tympani ; b. Ant. inf. quadrant of
membrana tympani ; c, Post. sup.
quadrant of membrana tympani ; d^
Post. inf. quadrant of membrana
tympani ; e, Niche of the fenestra
rotunda.

quadrant. Only seldom is a portion of

the canalis pro. tensor tympani visible.

(2) The ant. infer, segment (b) of

the internal wall of the canity next the

ostium tubae, together with a portion

of the jagged infer, ant. wall of the ca^dty, corresponds to the ant. infer.

quadrant.

(8) Above the ambos-stapes articulation, behind it the apex of the eminentia
stapedia and the tendon of stapedius muscle ; below the same the larger and
upper portion of the niche of the fenestra rotunda ; all these correspond to
the post, super, quadrant (c).

(4) Above the small lower portion of the niche of the fenestra rotunda,
and below a portion of the rough wall of the cavity ; these correspond to the
post, infer, quadrant (d).

The relations as given here of the inner wall of the cavuni tympani show
many variations which must be borne in mind by ocular inspection or
operative procedures. The long process of the incus and its articulation,
with the stapes, often Ue so low that the greater part of the niche of the
fenestra ovalis, with the posterior crura of the stapes and stapedius tendon, is
easily %isible ; in other cases this connection of the incus and stapes is so

* Rtahnq/dopadie dtr mtd, Wissenschaften. Wien, 1866. Article Gehororgan.

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TOPOGRAPHY OP THE SOUND-CONDUCTING APPARATUS. 53

high that it is completely hid from view by the annolus tympanicDS, or only
Tiaible by complete destruction of the membrana tympani. The niche of

FlO. 57.— VSRTIOAL SsonON OF THB EXTSBNAL MEATUS, MbMBBANA TtHPANI, AND

Tympanic Oavitt.
a, Cellalar spaces in the superior wall of the meatus, connected with the middle ear ;
6, Roof of the tympanic cavity ; c, Inferior wail ; d. Tympanic cavity ; e, Mem-
brana tympani ; /, Head of the malleus ; g. Handle of the malleus ; A, Incus ;
ij Stapes ; k, Canalis Fallopiie ; /, Fossa jugularis ; m, Glandular orifices in the
external meatus. (Right ear.)

the fenestra rotunda often is so low that it appears to lie in the region of
the poet, infer, qoadrant only.
Since the membrana ia bulged inwards in a funnel-shape, and the inner

h di

ac h g

Fig. 58.— Horizontal Sbotion of the Eab.
a. Anterior wall of the osseous meatus ; 6, Its posterior wall ; c, Section of the mem-
brana tympani, of the handle of the malleus, and of the posterior pouch ; d, Pro-
monUn^ ; e, Ostium tymp. tubas ; /, Stapes in connection with the inferior
extremity of the lonf process of the incus and of the tendon of the stapedius ;
g. Mastoid process ; A, Cochlea ; i. Vestibule ; k. Carotid canaL

wall of the cavity, on the other hand, is bulging strongly outward, the
diameter of the cavity varies very considerably in its different portions.

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TOPOGRAPHY OP THE BOUND-CONDUCTING APPARATUS.

The dearest conception of the topography of the tympanic cayity is obtained
from vertical and horizontal sections (as represented by the accompanying
Figs. 57 and 68), or by corrosion preparations.

The distance of the membrane at its umbilical depression from the pro-
montory is on an average 2 mm. Below this spot and at a distance of 1^
mm. is that part of the promontory which is carved most strongly oatwards.
The distance from this point to the membrana tympani is about 2^ mm.

Fio. 59.— Fbontal Siotion of ths Innkb Ttmpanio Wall thbodgh thb Two
Labtrinthinb Fenbstra.

8f BasiB stapedis ; n, Niche of the fenestra ovalis with a portion of the cms of the
stapes, which has been divided obliquely ; o, upper, u, lower wall of the niche ;
pr, Section of the promontory with its muoous covering ; m, Membr. fenestra
rotnndse ; nr. Niche of the fenestra rotunda ; p, Lamina spiralis secundaria ;
/, Section of the n. facialis ; v. Vestibule. After a preparation in my collection.

Aooording to Bezold, the distance of the post, infer, quadrant of the mem-
brane from the inner wall of ibe cavity varies from 5 to 7 mm ; in the anter.
super, quadrant, according to my measurements, from 5 to 6 mm., and in
the anter. infer, quadrant from 4 to 5 mm. In the newly-born infant and
during the first year the distances are less.

The position of the ossicula and their relation to the waUs of the tympanic
cavity are rendered clear by Fig. 57. The head of the malleus and the body
of the incus lie in a niche-like excavation in the outer wall of the upper

Digitized by VjOOQIC

AUfilCLE. 55

portions of the tympanic oavity. Their immediate Ticinity to the exter.
super, wall of the cavity facilitates the formation of abnormal adhesions
between these ossicnla and the walls of the cavity. The stapes, which is
nearly at right angles to the malleus and incus, lies with its crura in a small
niche in the inner wall of the cavity leading to the fenestra ovalis, which
may be compared to a short dact It then not infrequently happens that
both crum come into immediate contact with the lower wall of the niche^
whereby in cases of inflammation of this region anchylosis of the crura
stapedius is favoured.

The topography of the mastoid process has been already given (page 46) ;
the position of the Eustachian tube, more especially that of the ostium
pharyng. tnbss, which is so important in catheterization, will be given in the
proper section.

PHYSIOLOGY OF THE SOUND-CONDUCTING
APPARATUS.

A. Auricle.

The auricle is of less importance to the functions of the human ear
than has been generally supposed by older authors. Each of the
depressions of its anterior surface has been supposed to play an
important part in the reflection of sound. On the other hand, the
auricle has been represented as an accessory formation of no
importance to the conduction of sound to the membrana tympani.
The latter view has been based upon the fact, that no noticeable
disturbance of hearing has been observed in individuals who had
lost the auricle from frost-bite or by mechanical injury.

Bat there can be no doubt that the auricle plays a considerable part in the
conduction of sound to the membrana tympani, although not to the same
degree in man as in some animals. The concha, that large recess on the
auricle already described, is the principal depression on the exterior surface,
collecting a portion of the waves of sound that strike the ear, and reflecting
them into the meatus. Schneider has proved that a decrease in the power
of hearing takes place if this depression is filled up with wax. To test the
influence of the auricle upon the reflection of sound, I experimented on
individuals who were hard of hearing, because in such persons the distance
of hearing for continuous sound is much more sharply defined than in persons
whose ears are normal. Now, the head of the patient being placed in a fixed
position, and the hearing-distance being ascertained by a metronome, which
is then placed somewhat within the boundary of the hearing distance, the
sound of the instrument will at once be lost to the patient when the concha
is covered by a stiff piece of paper. In this experiment the external orifice

Digitized by VjOOQIC

56 AUBICLE.

of the ear must remain free. No alteration in the hearing-distance will take
place if the other depressions on the anricle are covered.

That the size of the auricle and its angle to the head have an influence
upon the reflection of sound into the meatus will be seen from the fact that
persons of normal hearing, as well as those who are hard of hearing, will
hear more distinctly and more fully, if they bend the auricle forward by
pressure upon its posterior surface, or if they augment the surface of the
auricle by the hollow of the hand. Therefore, although the loss of the
auricle will not have defective hearing as its consequence, the sound will
certainly not be perceived so distinctly and fully as if the auricle were in
its place.

As the result of examinations made by me, I must consider the tragus of
great importance for the reflection of waves of sound which strike the
auricle. In front and slightly overlapping the external orifice of the ear,
the tragus appears as a nipple-like projection directed backwards, and by
this means a considerable space is formed opposite the concha and the orifice
of the external meatus. In this space the waves of sound reflected by the
auricle (concha) are collected, and are thrown into the external orifice of the
ear.

The importance of the space formed by the tragus can be tested by
modifying the above-described experiment, by putting cotton-wool steeped
in oil into the recess opposite the concha. By this means the sound of the
metronome will either be weakened or will totally disappear. On the other
hand, the sound will be heard considerably increased if the surface of the
tragus is enlarged backwards by placing a small firm plate against it.

It is therefore beyond doubt that the auricle intensifies the perception
of sound considerably by reflecting the waves of sound into the external
meatus.^

The muscles which are inserted into the cartilage of the ear have only a
subordinate influence upon the position of the auricle in man during the act
of hearing. On the whole, spontaneous movements of the cartilage of the
ear are rare. On the other hand, I observed frequently during the testing
of the hearing-distance reflex motions of the auricle, of which the patient
knew nothing, and which were visible sometimes in different portions and
sometimes over the whole auricle.

B. Conduction op Sound in the Externaij Meatus.

The waves of sound which advance in the column of air in the
external meatus are reflected several times by its many curvatures.
This refers, however, only to those waves of sound which are
reflected into the meatus by the auricle, or which strike the walls

* Kiipper, J./. 0., vol. viii, wholly deuies that the auricle exerts any influence
on the collection and reflection of the waves of sound. Mach holds the auricle for
* resonator for the higher tones, whose working depends partially upon its position
against the direction of the waves of sound, modifying the tones so as to assist in
locating the direction from whence it comes.'

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CONDUCTION OP SOUND IN THE EXTERNAL MEATUS. 57

of the meatus perpendicolaxly. For waves of sound also reach the
niembrana tympani, which proceed through the meatus without
reflection.

In the reflection of vrsLves of sound from the walls of the meatus upon the
membrana tympani, two places in the external meatus must be mentioned
as of great importance ; one is the trough-shaped depression on the posterior
wall of the cartilaginous meatus, which commences immediately inside the
external meatus, and extends along the posterior superior wall to the middle
of the canal It is situated opposite the cavity formed by the tragus, and
collects the waves of sound which are thrown back from this place, to reflect
them again upon the anterior inferior wall of the osseous meatus.

Here we meet with the concavity, already described, which extends
over the inner portion of the anterior and inferior wall of the osseous
meatus, and is roofed by the membrana tympani placed obliquely upon the
axis of the meatus. This concavity has a parabolical curvature, and the
waves of sound which are collected here wiU strike the membrane very
powerfully, as the latter is situated opposite to it.

The waves of sound, however, as is well known, lose their intensity by
repeated reflection ; therefore a portion of those entering the ear must be
destroyed by the walls of the meatus. It is therefore probable that the
sound, which penetrates the ear, strikes the membrana tympani slightly
modified in its intensity.

The width of the meatus has only a slight influence upon the intensity of
perception of sound, as can be proved by pushing a little ball of wax towards
the middle of the canal, so as to diminish its lumen to a small fissure, after
having previously exactly fixed the hearing distance for the ticking of a
watch. The hearing-distance will be very little altered in this case, and the
strength of the ticking will seem hardly diminished. The temperature of
the external auditory meatus, according to Mendel (yirchoVs 'Archiv,'
vol 50), is about 0*2'' G. less than that of the axilla. Eitelberg^s measure-
ments gave a difference of from T to O'd"" C, but he occasionally found the
same temperature as in the axilla. According to the investigations of
Claude Bernard, increase of temperature follows section of sympathetic
of the neck, and also the facial nerve in both the auricle and external
auditory meatus, while by irritation of the facial centre in the medulla
oblongata a decrease of temperature results. In acute meningeal affections
temperature in the external auditory meatus has been observed 0*1° to 1*0^0.
above that of the axilla.

C. Propagation op Sound thbough the Membrana Tympani,

AND THROUGH THE OSSICULA.

a. Application of the Besults to the Pathology of the Ea/r^

The membrana tympani, which is set in vibration by the waves of
sound which pass through the external meatus, possesses the pro-
perty of transmitting tones of the most varied duration of vibration,

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58 PROPAGATION OF SOUND THBOUOH THE MEMBEANA TYMPANI.

not only one after the other, but also simultaneously, so as to be
uniformly perceptible.*

It must not, however, be looked upon as an elastic membrane ; from the
anatomical arrangement of its fibres it is rather a stiff membrane of little
elasticity, a quality which is of importance in so far as it prevents after-
vibrations, which would impair the distinctness of the perception of sound.
In spite of this property the membrana tympani possesses its own tone
(E'""), as has been proved by experimental research, but on account of the
stiffness of its fibres it is able to tone very little of itself.

The funnel-shaped depression inwards of the membrana tympani pro-
duced by the tension of the handle of the malleus, has an important influence
on its eminent function.

Helmholtzf has established, upon mathematical and experimental bases,
the fact that the power of resonance of curved membranes is incomparably
greater than that of flatly stretched membranes. He conducted the tones
of a stretched string by means of a wooden pin to a curved membrane
stretched across a glass cylinder, and found that its resonance extended over
a great part of the scale, and that the curved membrane was also brought
into intense vibrations, when high and low tones were produced, by elongating
or shortening the string. MacQi and Kessel:^ found that the excursions of
the posterior segment of the membrane in the living ear are greater than in
the other parts, and also that the vibration of the membrane, during the
phase of condensation of the waves of sound, travels in a circular manner
from the periphery to the centre, while in the phase of rarefaction it travels
in the contrary direction.

As has been already said, the membrane, besides its inward curvature, has
also a curvature in the opposite direction from the umbo towards the peri-
phery facing the meatus. The radiating fibres, which are stretched out
from the periphery to the handle of the malleus, represent a system of
stretched strings, § with the handle of the malleus as its movable bridge.
Through the semicircular curvature outwards, the radiating fibres offer a
favourable point of contact for the waves of sound to strike the membrane,
as Helmholtz asserts. My investigations in this direction show, however,
that the increase and transmission of the sound is the same whether the
membrane is concave or convex on the surface upon which the sound strikes.
Helmholtz has further proved that only a slight motion of the point of the
handle of the malleus takes place, in proportion to a relatively great excur-
sion of the membrane, and that, on the other hand, the membrane executes
a great excursion with only slight motions of the handle of the malleus.

* That the artificial membrane is able by the proper adjustment to transmit the
complioated combmations of sound waves is proved by the Edison phonograph.

t Die Mechanik der OehdrknOchelchen und des Trommdfells. Pfltiger's ArchiVy
voL i.

t Beitrdge zur Topographic und Meclianik des Mittelohres. Reports of Vienna
Acad. Session, April, 1874.

§ This statement was first made by me, and was repeated lately by Fick (A. /. 0.).

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PBOPAGATION OP BOUND THBOUQH THE MEMBRANA TYMPANI. 59

Fiok asserts that, in oonseqaenoe of the oblique plane of the membrana
tympaniy the waves of sonnd strike the ear in a less f avoorable manner than
if the membrane were placed perpendioolarly npon the axis of the meatos.
As, however, the waves of sound advance with a spherical wave-front, and
on the other hand the membrane is also curved, great importance must by
no means be attached to the inclination of the membrane as regards the
reception of the waves of sound.

Transmission of Sound from the Memhrana Tympani to the
Labyrinth. — The vibrations of the membrana tympani are partly
transmitted to the labyrinth by means of the ossicles and foot-
plate of the stapes, and partly through the air of the cavum tym-
pani acting on the fenestra ovalis.

While the older physiologists, especially Pascal and, at a more recent date,
Sapolini and Pecchi (// sordo muto^ Nov. 5, 1890), contended that the prin-
cipal means of sound transmission was by means of the fenestra ovalis,
physiological investigation and pathological-anatomical examination go to
prove that the chain of ossicles are the principal method of sound trans-
uiisston from the membrana tympani to the labyrinth.

Tl» oanonla form a system of senative leven, through which the vibra-
tions of the membrana tympani are transmitted to the labyrinth. The
disputed position as to whether in the transmission of sonnd through the ossi-
cular chain only a mutual movement of tin separate molecules of the ossicula
towards each other takes place, or whether the separate portions of the
chain, malleus, incus,, and stapes vibrate as whole bodies with ' extensive
oscillations, could only be determined by means of direct experiments in the
auditory organ.

By means of a series of experiments conducted by me in the year 1861
(Arch.f 0., vol. i.), I was the first to furnish experimental proof that the
ossicula vibrate as whole bodies, with extensive amplitudes under the
influence of the waves of sound which strike the membrana tympani.

After removal of the tegmen tympani and of the inner or labyrinthine
wall, fine threads of glass, 10-12 cm. in length, with the fibre of a feather
attached to their point, were fastened by means of resin one after the other
to the malleus, incus and the foot-plate of the stapes, and the tones of organ-
pipes of different height were conducted through the external meatus to the
membrana tympani.

The vibrations of the ossicula were rendered considerably more perceptible
by the sensitive glass levers which were fastened to them, and were plainly
visible to the naked eye. The vibrations may, however, be most distinctly
traced if the ossicula are made to register them themselves. For this
purpose a brass drum n used, which revolves round its longitudinal axis
and moves forward, is covered with paper and blackened by the smoke of a
turpentine lamp. If the point of the vibrating thread of glass is brought
iuto contact with the blackened surface of the cylinder quickly rotating,
regular spiral lines will be produced upon it.

These experiments have been made with simple and compound notes.

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60 PROPAGATION OF SOUND THROUGH THE 088ICULA.

With simple notes regular spiral lines were traced (Fig. 60, 1) ; with com-
pound notes, however, vibrations were created by the interference of the
waves of sound, which were visible upon the surface of the cylinder as regu-
larly recurring straight-lined places between the spiral lines (Fig. 60, 2).
The most regular drawing of this interference was obtained by the notes of
two organ-pipes, which were exactly an octave apart ; in each great spiral
curve of the deeper octave, the smaller curve of the higher octave was
inserted (Fig. 00, 3).

The proportion of the vibration of the ossicula depends principally on the
mechanism of the joints. In 180*2, I discovered by experiment (Wiener
Med. Wochenschrifi, Nos. 13 and 14) that every time the air is condensed
in the tympanic cavity, a considerable excursion of the membrana tympani
with the handle of the malleus outwards towards the meatus, and a distinct
motion of the articular surfaces of the malleus and incus, are visible, while
the excursions of the long process of the incus are very trifling. This is

FUt. 60, — SKLK-RBGI3TKRBD TRACINGS OK THK V1HRATION8 OK THE OSSICULA.

plainly a foreshadowing of Helmholtz's very recent description of the
mechanism of the articulation of the malleus and incus. As already men-
tioned, he compares that articulation with the mechanism of the catch -
contrivance inside a watch-key. With the excursion inwards, the cog of the
malleus catches exactly in that of the body of the incus, causing the latter
bone to follow the motion. With the motion outwards, however, the cog
of the malleus unhooks itself from that of the incus, and the malleus prin-
cipally is moved outwards, the incus being so only in slight degree.

The relative range of the motion of the separate bones may be ascertained
by the method indicated by me, in the following manner. Threads of glass
of equal length are fastened to the malleus, incus and stapes, and the mem-
brana tjrmpani is brought into motion by condensation and rarefaction of
air in the external meatus. It will then be seen that the sensitive glass
lever on the malleus executes much greater excursions than that on the
incus, and that the excursions of the thread of glass fastened to the stapes
are the slightest. By the same method I have also proved* that the axes of
the ossicula are not fixed, but movable ; and I have made the statement
that in transmitting the waves of sound from the membrana tympani to the
labyrinth, the vibrations of the malleus are greater than those of the inous,
while those of the latter are again greater than those of the stapes.

* Woe/ieMcUi der OewlUchaft der Aerzle, No. viii., 1868.

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PBOPAGATION OF SOUND THROUGH THE OSSICULA. 61

These assertions haye been confirmed by Sohmiedekam.* Dr. Bock of
New York afterwards made use of another method to trace the vibrations
of the ossicnla. It is on the principle of Lissajoas, based upon the optical
examination of the yibration of bodies. f Back fastened starch granules to
the oedcula, and examined their yibrations by means of a microscope sup-
plied with a micrometer. The starch corpuscle, which was fixed under
the microscope, and which appeared as a whitish spot when at rest, expanded
during the yibration of the membrana tympani and the ossicula into a line,
the length of which for each of the bones could be measured by the micro-
meter. Buck has proyed by this method, which has the advantage that the
ossicnla are not weighted during the experiment, that the yibrations of the
malleus are twice as strong as those of the incus, and four times as strong
as those of the stapes. The greatest excursions take place at the tip of
the handle of the mallens, 0*76 mm. ; those of the long process of the incus,
0*21 mm. According to Helmholtz, the greatest excursions of the stapes
amount to i^g-iV °^™« These measurements are, howeyer, only to be
assumed in the case of extensiye excursions of the ossicula, when they are
brought into motion by alternate condensation and rarefaction of the air in
the external meatus or in the tympanic cayity. During yibrations caused
by sound, howeyer, the excursions of the stapes are yery trifling, and
Riemann correctly remarks, that with weak, but still plainly perceptible
notes, they must be so slight as not to be discernible even with the most
powerful microscope.

The motion in the sound-conducting apparatus is compared by Helmholtz
to that of an nnequal leyer, which executes great excursions at one side, and
small ones at the other. If, according to the foregoing, the excursion of the
yibrations is decreased as the waves of sound progress through the ossicula
owing to the bulging in the membrana tympani, their intensity is by no
means lessened.

By the mode of articulation of the malleus and the incus, the organ of
hearing is protected from violent concussions acting upon the membrana
tympani. When, by a sudden condensation of the column of air in the
meatus, the membrane with the whole ossicular chain is rapidly forced
inwards, the violent shock which would fall upon the labyrinth is prevented
by the outwardly convex arches formed by its radiate fibres, stretched
between its two end points, the annulus tympanicus and handle of the
hammer. For the shock falling upon the convexity of these arches serves
to straighten them, and in this way the handle of the malleus is arrested in
its excursion inwards, before it has exerted much force on the incus.

The labyrinth is also protected against excessive variations of pressure,
due to the sudden entrance of air into the tympanum, because, as already

* ExperimtnUUt Stttdien zur Physiologie dea Gehdrorgana, Inaugural Disserta-
tion. Kiel, 1868.

t Mach and Kessel (/. c.) made tise of the same method to ascertain the axes of the
ossicula during vibratioDs caused by the sound. They found that the stapes performed
no piston-like motion in the fenestra ovalis, but that it revolved round an axis
situated near the inferior margin of the foot-plate of the stapes, so that the superior
margin penetrates deeper towards the vestibule than the inferior margin.

Digitized by VjOOQIC

62 PKOPAGATION OP SOUND THROUGH THE OSSICULA.

mentioned, the membrana tympani with the handle of the malleus is moved
outwards to a considerable extent, while the incus and the stapes follow this
motion only in a slight degree.

The resistance to the vibration of the ossicula is caused partly by their
articular ligaments, partly by the fibrous ligaments and folds of mucous
membrane which extend from the walls of the tympanic cavity to them.
These obstacles are of the greatest importance in favouring the uniform
reception and conduction of the waves of sound, which vary in the duration
of their vibration (Biemann, Helmholtz). They give the ossicular chain
a sufficient amount of stability, by which the necessary proportion between
the tension of the membrana tympani and that of the ossicula is effected.

Application of the Besults to the Pathology of the Ear. — ^The
anomalies which arise between the tension of the membrana
tympani and that of the ossicula owing to pathological changes
must impair the propagation of sound. In cases of closure of the
Eustachian tube an increased tension of the membrana tympani
arises by rarefaction of air in the tympanic cavity, which will be
followed by increased tension of the ossicula. The result of this is
an abnormal increase in the obstacles and a hindrance in the con-
duction of sound to the labyrinth. Cases will also occur where the
membrana tympani gets thinned and atrophied — from excessive
pressure^-on one side for a long time, or by extensive cicatricial
formation, whereby it loses its normal degree of tension. Here also
the anomaly between the tension of the membrane and that of the
ossicula will cause a disturbance of the functions. This also holds
good with regard to those pathological processes in the middle ear,
where the tension of the membrana tympani is not altered, but
where obstacles are created by diseased products at the joints of the
ossicula, or in places where they come in contact with the walls of
the tympanic cavity, which produce a hindrance to the conduction
of sound.

The principle of Lissajons, made use of by Buck, I have applied in a
number of experiments, the results of which are of importance in the
explanation of functional disturbances, observed in consequence of patho-
logical obstacles to the conduction of sound in the middle ear. As a point
on the ossicula, if fixed by a microscope, appears as a line during^ their
vibration, the intensity of the vibrations was measured during these experi-
ments by the alteration in the length of this line. The results of tiiese
experiments, published by me in 1871 {A.f, 0., vol. vi.), are as follows :

1. If the tones of aliarmonium are conducted by means of a tube to the
membrana tympani of an anatomical preparation of the ear, it is found, that
with equally intense tones the intensity of the vibrations of the ossicula is
less with deep tones than with high ones above the middle range, while with
very high tones the intensity decreases again.

Digitized by VjOOQIC

PBOPAGATION OP SOUND THBOUGH THE OBSICULA. 63

2. If words are spoken into the meatns through a hearing- trumpet, the
ossicnla exhibit as many oscillations as there are syllables in the word. The
greatest excursion of the oscillation coincides with the yowel of the syllable.

3. If some portions of the membrana tympani are weighted with a small
ball of wax or a little rod, the intensity of the yibrations of the ossicnla
decreases only in a slight degree ; but if the malleus or other ossiculum is
weighted in the same manner, and an obstacle to the conduction of sound is
thereby created, similar to the exudations and adhesions which have arisen
from disease of the middle ear, the excursion of the vibration is considerably
diminished.

4. If deep or high tones act upon the membrana tympani while the
ossicnla are weighted as above, a comparatively greater vibration will be
observed with high than with deep tones. The vibrations will also be
notably less during the speaking of words into the meatus, than during the
impact of musical tones.

These results agree with the disturbances of hearing observed in patients.
Alterations on the membrana tympani, as cicatrices, calcifications and
perforations, will impair the power of hearing less than pathological pro-
ducts (adhesions, anchylosis) in the ossicnla, which diminish their power of
vibration. It will ako be seen, that in such cases high tones are mostly
heard better than deep ones, and that the perception of speech is more
affected than that of musical tones.

5. If the membrane is artificially destroyed, the vibrations of the malleus
become less; but if an artificial membrana tympani is inserted, and its
india-rubber plate is brought into contact with the handle of the malleui^,
the vibrations will again become stronger.

6. The jingling sounds in the ear, observed by Helmholtz after intense
concussions, are in my opinion not caused by the striking against each other
of the cogs of the articulation of the malleus and the incus, but, as my
experiments have shown, by the whizzing of the membranes and ligaments
of the ossicnla ; for these jingling tones can be produced in the ear of a
dead body by the tone of an organ-pipe, even if the articulation of the
malleus and the incus has been artificially anchylosed.

D. Physiology of the Eustachian Tube,

It is well known that when the mouth and the nose are closed,
air can be forced into the tympanic cavity by means of a powerful
act of expiration, by which the membrana tympani will be somewhat
forced outwards. This is called the Yalsalvian experiment. By the
condensation of air in the tympanic cavity, which results from this
experiment, a sensation of fulness and tingling in the ear, and a
slight degree of hardness of hearing, especially for deep tones, are
brought about.

A similar sensation will be perceived if the act of swallowing is
performed when the mouth and nose are closed. But in this case

Digitized by VjOOQIC

64 FUNCTION OP THE EUSTACHIAN TUBE.

the air in the tympanic cavity is not condensed (Toynbee), but, as I
was the first to prove, rarefied, as part of the air in the pharynx is
swallowed, and the rarefaction of air extends from the pharynx
through the tube to the tjrmpanic cavity.

If the nasal orifices are opened again after the act of swallowing,
the sensation of tension in the ear nevertheless remains ; it will only
disappear when the act of swallowing is repeated with the nasal
orifices unclosed.

This can be simply explained. The Eustachian tube is opened
wide, during the act of swallowing, by the action of its muscles, and
the rarefaction of air arising in the pharynx extends to the tym-
panic cavity. Immediately after the act of swallowing, however,
the walls of the tube lie again close together, and the air in the tym-
panic cavity remains rarefied, while the atmospheric pressure again
prevails in the pharynx. As there is now a difference in the pressure
of air in the tympanic cavity and in the pharynx, the membranous
wall of the tube is pressed closer to the cartilaginous wall by means
of the external pressure of air, so that the closure of the Eustachian
tube is more complete than it is in ordinary circumstances. If now
another act of swallowing be performed, the tube will again be
opened, and the pressure of air in the tympanic cavity and in the
pharynx will be equalized.

These results followed from a number of experiments performed by me,
in 1860, in the laboratory of C. Ludwig. I made use of a small glass tube,
2-3 mm. wide, fitted into an india-mbber stopper (ear-manometer, Fig. 61),
and famished with a drop of coloured flaid. This tube was hermetically
sealed into the external meatus. During the Yalsalvian experiment, the
fluid in the manometer was seen to rise. If an act of swallowing were
performed with the closed month and nose, during the
first stage of this act a slight rise (positive flactnation)
of the flnid in the manometer took place, followed,
however, daring the second stage of the act of deglu-
tition, by a considerable fall (negative flnctuation), as
the air in the tympanic cavity is rarefied and the mem- f,g. 61.— Eab-
brana tympani is pressed inwards. The flnid will now manombtbb.

remain in the place where it fell to after the act of swallowing, and will
return to its former place only when the closed Eustachian tube is reopened
by another act of swallowing with open nostrils. In many cases, and even
in the same individual, slight fluctaations of the flnid in the manometer will
be observed even with quiet respiration, corresponding with the respiratory
movements ; these fluctaations will be greater the more quickly the air is
allowed to pass through the nose, and when a greater obstacle is presented
to the passage of air by closure of one of the nostrils.

The opening of the Eustachian tube during the act of swallowing can also

Digitized by VjOOQIC

PUNC5TI0N OP THE EUSTACHIAN TUBE. 66)

be proved by another simple experiment, which was first performed by me
in 1869. If a vibrating tuning-fork is held in front of the nostrils, a
uniformly weak sound will be heard in both ears ; during an act of swallow-
ing, however, the tone of the tuning-fork will be perceived in both ears
greatly increased, as its vibrations penetrate unchecked into the tympanic
cavity through the open Eustachian tnbe.

It has already been pointed out, that the surfaces of the mucous mem-
brane in the middle portion of the Eustachian tube come into contact with
each other on all sides. This portion of the cartilaginous tube is sometimes
large and sometimes very short, as I have observed in a number of prepara-
tions, which explains the normal individual dififerences observed in regard
to the amount of hindrance to the passage of air along the tube from the
pharynx.

The of t'discassed question, whether we can hear through the Eustachian
tube, and especially whether we can understand speech, when the conduction
of sound by means of the external meatus and the membrana tympani is
excluded, will be decided in a positive manner by the following experiment.
An individual of normal hearing, whose meatuses are so firmly closed by
means of the m(»stened fingers that he cannot understand speech at a
distance of one meter, has the ear-piece of a hearing trumpet of the same
length inserted into the orifice of the nose, and the nostrils are closed round
it by another person. The person experimented on will now at once
distinctly hear speech, which he could not understand before, if it is spoken
into the hearing- trumpet. That many persons can understand whispered
speech, while others only understand loud speech during this experiment, is
due to the fact that the walls of the Eustachian tube vary individually, in
respect to the closeness with which they are applied to each other. But
from this fact the conclusion can by no means be drawn that the tube is
open, as speech can also be understood through an india-rubber tube, the
walls of which lie loosely together for a short distance.

These anatomical observations and experiments give the following results :

1. The Eustachian tube is not constantly gaping ; its permeability varies
individually, as in a number of cases a current of air from the pharynx
towards the tympanic cavity takes place even during quiet respiration,
while in other cases an act of deglutition, or a powerful expiration with
opened or closed nostril?, is necessary to make the tube passable for the
current of air.*

2. The Eustachian tube is opened during the act of swallowing chiefly by
the action of its muscles, especially the abductor tubsB (v. TroIt8ch),t as is
proved by the experiments of Toynbee X Ai^d myself.

* Oonfirmed by Mach and Kessel : Die Function der Trommelh6/de und der Tuba
EitJiUichnt Vienna Acad. Reports, 1872.

f Daring experiment? on vivisected dogs I succeeded in observing a widening
of the fii^are of the tube in the wall of the pharynx by the irritation of the trigeminns '
in the cranial cavity. The dissection showed that the widening was caused by the
tensor palat. molL Ceher eine Berziehung dea Trigeminus zur Eust. Ohrtrompete,
Wiknburgtr nalurunsseMcha/tlidie Zdtschrift, 1861.
X Diseases iif the Ear, ISQO,

Digitized by VjOOQIC

66 APPLICATION TO THE PATHOLOGY OP THE EAB.

:5. When the air-pressure in the tympanum exceeds that in the pharynx,
or vice versdj equalization of the pressure will be brought about by the
passage of air from the one cavity to the other ; but the passage of air from
the former to the latter takes place more readily tban from the latter to the
former.

E. Application to the Pathology of the Bar.

Id regard to the pathology of the ear, the following considerations
result from the above physiological facts :

1. The permeability of the Eustachian tube is of great importance
for the function of the organ of hearing. If the tube become
impermeable by swelling of the mucous membrane, or by accumula-
tion of secretion, the consequences of the interruption to the
exchange of air between the external atmosphere and the tympanic
cavity will shortly become apparent. By exclusion of the air from
the tympanum, and consequent rarefaction of the air in that cavity,
congestion of its tissues and exudation into it will often follow.
As the external pressure of air preponderates, the membrana tym-
pani and the ossicular chain become tensely stretched and forced
inwards by it, and are partially deprived of their power of vibration.

2. By the opening of the Eustachian tube during the act of swal-
lowing, the resistance which is opposed to the current of air from
the pharynx to the tympanic cavity is considerably lessened. Where
it is necessary, therefore, in disease of the middle ear, to render the
tube permeable, and to employ the action of a strong current of air
in the tympanic cavity, the effect will be materially increased if,
during the inflation, an act of swallowing is performed.

F. On the Influence op the Variations op the Aib-pbessube
IN THE Tympanic Cavity upon the Tension op the CJontents

OP THE LaBYBINTH.

The sensation of fulness or tension in the ear, accompanied by a
tingling and slight degree of hardness of hearing, which arises from
condensation or rarefaction of the air in the tympanic cavity, has, since
the time of J. Miiller, been attributed to altered tension of the mem-
brana tympani. In the explanation, however, the pressure upon the
elastic membrane of the fenestra rotunda, and upon the foot-plate
of the stapes with the membrane bordering on it, and consequently
upon the whole contents of the labyrinth, remained totally dis-
regarded.

To prove that, as I supposed, an alteration in the amount of tension of
the contents of the labyrinth would take place with inoreHed or decreased

Digitized by VjOOQIC

VARIATIONS OP THE AIR-PRESSURE IN THE TYMPANIC CAVITY. 67

pressure in the tympanic cavity, I instituted a number of manometrical
experiments on fresh humap ears (in Prof. Lud wig's laboratory), during
which the oondensation and rarefaction of air in the tympanic cavity were
produced by an air-pump (Fig. 62) connected with the Eustachian tube
(c). A manometrical tube, partly filled with a solution of carmine (A), was
introduced into the opened superior semicircular canal, and fastened hermeti-
cally. Now, when the air in the tympanic cavity was condensed by com-
pression of the balloon, an outward curvature of the membrana tympani and
also a rising of the fluid in the manometrical tube in the labyrinth (A)—
positive fluctuation of 1^-3 mm.— were observed, while during rarefaction a
distinct fall of the fluid in the manometer was noticed. If the fenestra
rotunda is closed by wax, a decrease in the flactuation of the fluid in the
manometrical tube will take place daring condensation of air in the tympanic

Fio. 62.

a, Eztenoal meatus ; b. Tympanic cavity ; c, Eustachian tube ; d, Vestibule of the
labyrinth ; e. The superior semicircular canal with the manometrical tube intro-
duced into it ; /, The cochlea with the acala vestibuli and tympani ; g. Fenestra
rotunda.

cavity. If the articulation of the stapes and incus is severed, an increase in
the fluctuation of the fluid to the extent of ^-1^ mm. results in consequence
of the resistance, which was formerly opposed to the motion inwards of the
stapes being removed.

Bezold, whose manometrical experiments led to similar results, found on
testing the membrane of the fenestra rotunda alone that it was capable of
an excursion of more than ^ mm., while that of the foot-plate of the stapes
did not exceed ^ mm. The possible extent of the exoursionB of the
membrana fenestra rotunda is thus flve times greater than that of the foot-
plate of the stapes.

From these experiments it is shown :

1. That by condensation of air in the tympanic cavity, not only does an
alteration in the tension of the membrana tympani take place, but by
aimultaneous action on the membrane of the fenestra rotunda and on the

Digitized by VjOOQIC

68 FUNCTIOK OP THE INTRA-TYMPANIC MUSCLES.

movable foot-plate of the stapes, the pressure on the contents of the
Uibyrinth is considerably increased. The extremities of the auditory nerve,
surronnded by the auditory fluid, are mechanically irritated by this increased
pressure, which will cause subjective sensations of sound. The slight degree
of hardness of hearing can be explained in a similar manner to the dis-
appearance of the perception of light when a moderate pressure is exerted
by the finger on the eyeball. The fact that in this case hardness of hearing
for deep tones especially occurs, while high tones can still be heard com-
paratively well, has to be attributed to the altered tension of the membrana
tympani ; but it must not be lost sight of, that at the same time also the
structures of the labyrinth (lamina spiralis membranacea and membranous
saccules) are more tightly stretched, and that they will vibrate with greater
difficulty in response to deep tones.

2. In the above experiment an explanation is to be found for the
subjective noises and disturbances of the function of hearing, so often
accompanying those diseases of the ear in which, by accumulation of serous
or mucous exudations, or by the new formation of connective tissue in the
tympanic cavity, the two fenestrsa of the labyrinth are abnormally weighted,
or in which the membrana tympani and the ossicula are pressed inwards, the
tension in the labyrinth being abnormally increased by the excessive pressure
of the foot-plate of the stapes.

G. Function of the Intra-tympanic Muscles.

Our knowledge hitherto concerning the action of the intra-
tympanic muscles relates to the mechanism of the increase and
decrease in the tension of the membrana tympani, and also to the
regulation of the intra-tympanic pressure. In what manner they
take part in the act of hearing has not been proved. Concerning
the influence of the tension of the membrana tympani upon the per-
ception of tones, I have proved {A, f, 0., vol. i.) by experiments on
hiunan ears, as well as on preparations of the same organs from dogs,
which had just been killed, in which the tensor was made to contract
by electrical irritation of the trigeminus in the cranial cavity, that,
especially during testing with deep tones (tuning-forks), a softening
down of the key-note and a greater distinctness of the upper notes
is observable.

Hansen and Bockendahl,* who opened the cavum tympani of dogs and
i^ttached a light, sensitive lever to the tendon of the tensor tympani muscles,
ob erved a reflex contraction of that muscle on sounding musical notes. J.
Pollak,t who substantiated these results, found that the energy of the
contractions was, as a rule, greater for high than for deep notes, was strongest
for the vowel a, very slight for u, and further, that by the action of musical

* Arch.f. Ohrenheilk.y vol. xvi.
t Med, JahrlMdier, Wien, 1886.

Digitized by VjOOQIC

FUNCTION OF THE INTRA-TTMPANIC MUSCLES. . 69

notes on the one ear a reflex contraction of the mnscle of the other could be
brought about. Destruction of both labyrinths is accompanied by complete
disappearance of the reaction of both tensor tympani muscles.

I have experimentally proved that the action of the tensor is not confined
alone to the membrana tympani, but that it extends also to the labyrinth, as
I observed a motion of the fluid in the labyrinth on electrical irritation of
the trigeminus in the cranial cavity. The tensor tympani increases, there-
fore, the pressure in the labyrinth.

Recently, Dr. Secchi, docent at Bologpia, has experimentally proved on
dogs and cats, by means of a manometer tube hermetically placed in the
osseous bulla : 1. That the pressure of air in the cavum tympani, through
the action of the muscles of the tube or in connection with the intrinsic
muscles of the ear, is higher than the external atmospheric pressure. 2. That
the intra- tympanic air-pressure is increased by tones or noises, on account of
the contraction of the tensor tympani muscle. 3. That the stapedius mnscle
is to be considered an antagonist to the tensor tympani, for it relaxes the
membrana tympani and lessens the pressure in the labyrinth, as Politzer first
experimentally proved by irritation of facial nerve in the cranium (Wiener
Medicinalhalle, 1867).

From examinations conducted hitherto, we can at present only state that
it is one of the principal functions of the intra-tympanic muscles to remove
the alterations in the position and tension of the ossicular chain and of the
contents of the labyrinth, which are caused by the variable fluctuations in
the air-pressure, in fact, to regulate the degree of tension of the hearing-
apparatus.

I was the first to state the view, upon the basis of observations on myself
and on aural patients {A. f, 0., vol. iv.), that the deafness which occurs
during yawning is brought about by a simultaneous motion of the tensor
tympani. This view was confirmed by Helmholtz (Z. c).

Concerning the spontaneous contractions of the tensor tympani, Luschka
and I advanced at the same time the opinion, that the cracking noises in the
ear, which many persons can cause spontaneously, arise from the contraction
of the abductor tubae. The observations of spontaneous contractions of the
tensor tympani have only rarely been made (Schwartze, A, /. O., vol. ii. ;
and LucflB, ibid., vol. iii.). In a case described by me (A, /. 0., vol. iv.),
involuntary as well as spontaneous contractions of the tensor were observed
in both ears.

Luc» first observed that by contraction of isolated muscles of the face,
most easily by the musculus orbicularis, a simultaneous contraction of the
stapedius can be produced. This produces a deep humming sound in the
ear and also, a relaxation of the tympanic membrane, as is shown by the
manometer. During such reflex contractions the perception of the deeper
and middle tones of the tuning-fork is destroyed.

Digitized by VjOOQIC

70 EXAMINATION OF 9XTEBNAL MEATUS AND MBMBBANA TYMPANI.

II. THE METHODS OF PHYSICAL EXAMINATION OF THE
OBGAN OF HEARING.

A. The Examination of the External Meatus and Membrana

Tympant.

Examination of the external meatus and of the membrana tym-
pani is indispensable to the knowledge of pathological changes in
the organ of hearing. The membrana tympani, being covered on
the outside by the cutis of the external meatus, and on the inside
by the mucous membrane of the tympanic cavity, is in intimate
relation to the affections both of the external meatus and of the
middle ear. The processes of disease going on in them cause
changes in the membrana tympani, which may be recognised by
ocular inspection, and enable conclusions to be drawn as to the
pathological state of the external and middle ear. Experience
shows that the diseases of the middle ear most frequently form the
basis of functional disturbance in this organ, and since these affec-
tions are often combined with changes in the membrana tympani, it
will be seen that the state of the latter is of great importance in the
diagnosis of affections of the former.

It muBt, however, be distinctly noted, that alterations in the membrana
tympani are obeerved in a oonsiderable nnmber of persons of normal bearing,
witbont the least distorbance of function. These alterations are to be con-
sidered as inherent anomalies, or as the residne of some pathological process
which has ended in complete cure. On the other hand, the membrana
tympani is perfectly normal in a considerable number of persons whose
hearing is disordered to a high degree. In spite of the diagnostic importance
of the conditions observed in the membrana tympani we are never able
to draw any conclusion from them as to the degree of functional dis-
torbance, for experience has shown that extensive perforations, cicatrices,
and calcifications are often accompanied by only a trifling disturbance in
hearing ; while, on the other hand, with only slight deviations from the
anatomically normal state a high degree of deafness is often observed.

As already mentioned, disturbances of the function in the case of diseases
of the middle ear are most frequently caused by those products of disease
which diminish the mobility and power of vibration of the ossicula.

Ear Specula, — ^The most practical method of examination which
is now in actual use is v. Troltsch's method with the conical speculum
and concave mirror. The bivalve form called Itard's or Kramer's
speculum, formerly used, has justly been laid aside on account
of its defectiveness in comparison with the more recent and more
reliable instruments.

Digitized by VjOOQIC

SXAMINATIOM OF EXTERNAL MEATUS AND MEBIBBANA TYMPANI. 71

The conical specala, first used by Deleaa and Ignaz Graber, and
modified in shape and size by Arlt, Toynbee, Wilde (Fig. 63), and Ehrhard
(Fig. 64), consist of metal, with a polished or blackened interior. They are
either fannel-shaped or like a truncated cone, and have a round or oval
aperture at their extremity ; bat this, as well as the shape of the speculum,
is of little importance.

The vulcanite specula (Fig. 65), which I brought into practice, have the
advantage of being considerably lighter than those of metal, so that they
remain in the required position, and also of not producing the unpleasant
chilly sensation of the polished metal speculum. Their black interior serves
to render the surface of the membrane more distinct by contrast, and with

Fig. 68.— WiLDi's

SPJiCULUlf.

Fig. 6t.— Ehbhabd's
Spjgculum.

Fig. 65.— The Author's
Speculum ok VuLCANrrE.

judicious illumination the view of the membrane will therefore appear
clearer than with the same ligbt reflected from a polished metal speculum.

The different sizes, 8, 6, 4, and 2 mm. in diameter at the aperture
(Fig. 65), are constructed to suit various meatuses.

Beflector, — These specula, combined with a reflecting concave mirror
perforated in the centre, 7-8 cm. in diameter and of 10-15 cm. focal
distance, allow, with sufficient light, an accurate view to be obtained
of such pathological changes as are perceptible in the membrane or
meatus.

For operations on the ear, when both hands are required for
manipulation, the mirror should be fixed to the head by Semeleder's
head-band, to which it is fastened by means of a ball-and-socket
joint in front of the eye of the observer. Each mirror can be so
constructed as to be used with a handle as well as a head-band.
In my practice I use a mirror fixed to the head by a strong half-
circle made of spring steel, and striking the forehead and occiput.
Schwartze and Trautmann use no special fixation apparatus while
operating, but direct the mirror with the thumb of the left hand on
which it is fastened by a movable ring.

Digitized by VjOOQIC

72 BXAMINATION OF EXTERNAIi IfEATUS AND MEMBBANA TYMPANI.

Befractive anomalies of the eye, which sometimes oocar, often necessitate
the application of corrective lenses to obtain a distinct view of the mem-
brana tympani. Persons of normal sight or short-sighted to a moderate
degree do not require these lenses. But persons with presbyopia or
hypermetropia miiet positively nse convex lenses, as most of them can see

the membrane only very indistinctly
withoat a corrective lens, while with one
suitable to the degree of the refractive
anomaly they not only see the membrane
distinctly, bat also somewhat magnified.
These lenses are best fixed by means of
a semicircle of vulcanite placed at the
back of the mirror and furnished with a
groove for the reception of the correcting
lens, and capable of being removed from
the aperture of the mirror by means of
a joint fixed to the upper extremity of
the handle (Fig. 67).

For the production of a magnified
image of the membrana tympani
bi-convex lenses are used, which by
means of a simple contrivance, de-
signed by Dr. Auerbefch of Hamburg,
are fixed obliquely at the entrance
of the speculimi. Moderate enlarge-
ments can also be obtained by convex
lenses of greater focal distance, which
are fixed as above on the posterior
surface of the mirror. By magni-
fying the membrana tympani many
changes, especially vascular ramifi-
cations, small deposits, projections
and depressions, movable exudation
and air-bubbles in the tympanic
cavity, come distinctly into view.
Such enlargements are of value chiefly
to persons with hypermetropia or
presbyopia, while short-sighted people can do without them.

Branton*s otoscope, in which the speculum, reflector, and magnifying lens
are combined in one piece, is so unmanageable that it cannot be recom-
mended to the practitioner. Weber-LiePs *ear microscope' and Yoltolini's
' ear lens ' have been determined useless.

The illumination of the membrana tympani is effected either by
ordinary daylight or by artificial light. The latter should be used

Fig. 66.— Concave Mirbob pib-
robated in the centre, with
Handle (half Size).

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BXAHINATION OP EXTERNAL MEATUS AND MEMBBANA TYMPANI. 73

in badly-lighted houses, on duU days, and at the bedside when the
natural light is insufficient. It is best to use either gas or a
petroleum lamp, although candle-light may be used for want of a
better. An intense light is given by the Auer's gas-light, which
consists of a network cylinder impregnated with certain metal salts
and is made to glow by means of a Bunsen burner. The effect
of petroleum and gas-light can be considerably intensified by the
use of convex lenses and reflecting mirrors. The examination with
compound lenses has the disadvantage of tiring the eyes by long use.
Artificial light has a farther disadvantage that the colour of the
membrane is more or less altered by it.

The electric light, the use of which has recently been recommended,
poflsesses no important advantages over that obtained from a good gas or
petroleum light. That form of electric
apparatus most frequently used consists
of an incandescent lamp, which is worked
by a pocket battery, and attached to
the forehead, throws a beam of light
directly into the meatus. The form
suggested by Claar, with an incandescent
lamp fastened upon a reflector, serves
the same purpose.

As a rule, however, ordinary day-
light, by means of which the shades of
colour of the membrane are perceived
in the most natural manner, is pre-
ferable, on account of its simplicity, to
all other methods of illumination.
This is especially the case with diffuse
daylight taken directly from a cloud,
or sunlight reflected on to the mirror
from a bright wall, that from a blue
sky being too dull. Artificial illumination is, however, preferable in dull
weather. Illumination by direct sunlight, which, according to Lucsb can
be managed with a plane mirror, is of use in demonstrating exudations in
the tympanic cavity, and for the clearer appreciation of the vascular ramifi-
cations and other minute changes in the membrana tympani. When using
diffuse daylight in brilliant sunny days, it is well to f oUow Wintrich's advice
and admit the light through a moderately large opening in the closed shutters.

Method of Otoscopy. — During the examination the head of the
patient must be placed so that the ear to be examined is turned
away from the light, and the rays which fall on the concave mirror
at an angle of 45* may be reflected directly into the lumen of
the external meatus, otherwise the head of the patient would
prevent a portion of the rays from reaching the mirror.

Fir,. 67.— POSTKBIOR VlIW OF THB

Concave Mirbob with Contrivancb

FOK THB RkOBPTION Of A CJORBBCTIVR

LvNs (half Sizb).

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74 EXAMINATION OF EXTERNAL MEATUS AND MEfifBBANA TYMPANI.

To insert the speculum into the meatus, it is necessary with the
left fore and middle fingers to draw the auricle a little backwards,
upwards, and also towards the observer, so that the axes of the
osseous and cartilaginous portions of the meatus, which form an
angle in their natural position, are brought into a straight line, thus
rendering a free view of the membrana tympani possible.

Then the speculum, slightly warmed, is inserted into the carti-
laginous meatus with a slight rotatory movement by means of the
thumb and forefinger of the right hand, far enough so that the hairs
which obstruct the view are completely turned aside. The intro-
duction of the speculum, especially in the case of older persons, often
causes a troublesome reflex cough, brought about by irritation of
the auricular branch of the vagus. Fainting fits and epileptiform
convulsions are more rare, though they occasionally occur. If the
instrument has penetrated to the osseous meatus, which can easily be
noticed by the slight resistance, any attempt to push it faxther must
be avoided, owing to the violent pain caused by pressure upon the
nerves of this part. The mirror, held in the right hand, slightly
reclining on the glabella, is brought near the ear, so that the rays
of light, reflected through the speculum, are focussed at the
membrana tympani. Care must be taken that the eye which is
behind the central opening in the mirror is in the line of the axis of
the speculum opening, and the practitioner should accustom himself
always to examine with that eye before which the mirror is placed,
both eyes being kept open all the time as in microscopy. It is, how-
ever, seldom possible to view the meatus and the membrana tympani
at once ; to view their separate portions one after the other it is
therefore necessary to move the speculum as well as the mirror in
all directions vdth the unoccupied thumb, which the observer's eye
must also follow through the central aperture.

In spite of the exaot observaiioe of these ioBtraotions, we get only an
imperfect view of the membrane in some oases, in conseqaenoe of varioas
obstractions whioh occar, sometimes in the cartilaginous, sometimes in the
osseous meatus. Among these obstructions may be mentioned : an abun-
dant growth of hair extending into the osseous meatus, collections of
cerumen, which, either in the form of plugs or deposits on the walls,
obstmct or narrow the meatus, epidermis scales, which, either as white or
mother-of-pearl-like membranes and strings, are stretched across the passage.
Large quantities of cerumen and detritus are best removed by soaking and
syringing, but smaller portions, such as are adherent to the walls, may be
remoyed by means of the vulcanite ear scoop, fatty deposits by a plug of
wooL Small ceruminal particles, detached epidermis scales, and membranes
are best removed with my forceps (Fig. 68), which have narrow, spoon-
shaped extremities and cross blades, and which possess the advantage that

Digitized by VjOOQIC

KXAIONATION OF BXTBSNAL MBATU8 AND MBMBBANA TYMPANI. 75

the opening of the blades in the meatus is less interfered with by the
■pecolam than in forceps without crossed blades. For the extraction of
small particles lying deep in the canal, the Sexton pincette is best adapted,
(r. * Extraction of the Hammer and Incus.*)

More important, becanse their removal is impossible, are the hindrances
to examination which arise from inherent narrowness
of the meatus, or from the abnormal bulging of the
anterior inferior wall of the osseous portion. This
constriction has as its consequence an insufficient
illumination of the range of view, while the more
or less pronoonoed bulging interferes with the in-
spection of the whole membrane so much, that the
portion before the handle of the malleas is completely
hidden, and sometimes eyen the handle of the
malleus can only partially be seen, the only part of
the membrane visible being the posterior superior
quadrant

Among the pathological changes which render the
membrana tympani temporarily or permanently in-
accessible for examination, are specially to be noted :
inflammatory affections of the lining membrane of
the meatus with stricture, accumulations of pus and
mncns, granulations, polypi and exostoses.

Normal State of the Membrana Tympani, —
When the membrana tympani is seen perfectly
and distinctly with proper illumination, its
colour, transparency, lustre, inclination, and
curvature, as well as the position of the handle
of the malleus and of its short process, have
separately to be considered. The relations of
these to each other collectively constitute the
characteristic appearance of the normal, as
well as of the pathologically altered membrane.

Concerning the colour of the normal mem-
brana tympani, it must be remembered that
this membrane is a more or less transparent
medium which reflects a portion of the light
thrown upon it, while it permits another por-
tion to pass through it and illumine the
tympanic cavity, from the opposite inferior wall of which a portion
of this light is reflected back through the membrane, and reaches
the observer's eya The colour of the membrane, as seen, is there-
fore composite, and depends upon its intrinsic colour, the kind of
light employed, and the quantity and colour of the rays reflected

Fig. 68.— BentFobobps
WITH Gross Blades.

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76 NORMAL STATE OF THE MEMBRANA TYMPANI.

back from the promontory. The nature of the light used has great
influence on the colour of the membrane. Thus, light reflected from
a blue sky imparts to it a pale blue colour, that from an oil lamp a
reddish-yellow tinge. Since the various segments of the membrane
are at different distances from the inner wall of the cavum tympani,
it follows that they appear to the investigator as being of different
colours, although the same kind of light is used throughout.

The normal coloar of the membrana tympani is best deaoribed as a
neatral or pearly gray, with a slight brownish-yellow tinge. The gray is
darkest in the anterior portion, at the angle between the handle of the
mallens and the cone of light, and lighter in the posterior portion. The
colonr of the latter part is in many oases modified at the superior boundary
by y. Troltsch's pouch, situated on the inner surface of the membrane.
This, with the chorda tympani, shines through the transparent membranes
as a whitish-gray opacity, extending from the handle of the malleos back-
wards. Behind the handle in the posterior superior quadrant, the lower
portion of the loug cms of the incus (Figs. 69 and 70) is often plainly
visible, and the posterior cms of the stapes with the stapedius tendon less
frequently so, if the membrane be transparent. The membrane is also
slightly yellowish-gray behind and a little above the inferior extremity of
the handle of the malleus, which is caused by the bone-yellow rays reflected
by the promontory. To this colour is often added a glimmering lustre, due
to the light reflected from a moist and smooth spot on the mucous membrane
of the promontory. A pronounced dark spot in the posterior inferior quad-
rant corresponds with the niche of the fenestra rotunda.

In childhood the membrane often appears grayish, opaque, and dim, but
not unf requently transparent and lustrous ; however, the gray colour of the
membrane is often much darker, and the promontory is much more fre-
quently seen shining through it. There are just as often changes in old age,
which are characterized by a uniformly gray and often lustreless appearance
of the membrane.

, At the inspection of the membrana tympani the short process of
the malleus, which is visible at the anterior superior pole as a white,
pointed protuberance, catches the eye first (Figs. 69, 70). It is con-
tinuous with the handle, which, imbedded in the membrane as a
yellowish- white stria, extends backwards and downwards, ending at
the umbo in a grayish, spatular expansion.

This ^umbilical opacity' on the membrane, as it is called by Trautmann,
is caused partly by the descending and radiating fibres of Prussak at the
umbo, and partly, as I have shown, by the deposit of small cartilaginous
cells round the lower extremity of the handle of the malleus. Besides that,
one finds at the anterior inferior periphery of the membrane a linear gray
opacity, corresponding to the annulus tendinosus.

Digitized by VjOOQIC

NOKMAIi STATE OP THE MEMBRANA TYMPANI.

The lustre of the membrana tympani is shown in the sharply
defined aiid usually triangular spot of light in the anterior inferior
quadrant of the membrane (Figs. 69 and 70). It commences with
its apex in front of the umbo, and extends forwards and down-
wards, so that it forms an obtuse angle forwards with the direction
of the handle of the malleus.

The shape of this light reflex varies greatly, partly on accoant of differ-
ences in the inclination of the membrane, partly on accoant of yariaiions in
its curvature. It is often intermpted in its continuity, so that between its
apex and its base there is a portion without reflection ; sometimes it seems
divided into two parts in its longitodinal direction, or delicately striped. It
seldom extends to the periphery of the membrane, and often the anterior
portion of the reflection is effaced, only its apex being visible in front of
the nmbo, as a small, irregular, Instroas spot. According to Bezold, this

Fia. 69. — Normal Mbm- Fig. 70. — Normal Msm-

BRANA TtMPANI OF BRANA TyMPANI OF

THX RiOHT Ear. thk Left Ear.

(Double size.)

spot is blurred in 86 per cent, of cases whose hearing are normal. The know-
ledge of all these variations in the normal state is of importance, because
they might give rise to erroneous interpretations of pathological changes.

As to the origin of the cone of ligbt, tbe examinations {A, f. 0., vol.i.)
made by me on artiflcial membranes and preparations of the normal auditory
apparatus have shown that its principal cause is the inclination of the
membrane to the axis of the meatus, in connection with the concavity of
the membrane produced by the handle of the malleoB. In consequence
of the carvature of the membrane brought about by tbe traction of
the handle of the malleus, the inclination of the various portions of the
membrane is so altered that its anterior portion is placed exactly opposite
the eye of the observer, and thns the incident rays are directly reflected to
the eye. The triangular shape of the cone of light is caused by tbe funnel-
shaped inward curvature of the membrane (TraUtmann).

The form and size of the cone of light undergo many changes in
the diseases of the membrana tympani and of the middle ear, which
are o( special diagnostic value, if we have an opportunity of observing

Digitized by VjOOQIC

78 NORMAL STATE OF THE MEMBBANA TYMPANI.

them during the course of the disease. On the whole, however,
these changes of the cone of light only aid the diagnosis in con-
junction with other symptoms, as similar alterations are often
observed in persons of normal hearing.

Of most importance in diagnosis are those changes in its form which arise
by variation of the pressure of air in the tympanic cavity, and which in
many cases can be used in determining the permeability of the Enstaohian
tube. For if air is pressed into the tympanic cavity, or the air in the
tympanic cavity is rarefied during an act of swallowing with closed nostrils,
a change in the form of the reflection of light will be obserred on inspection
of the membrana tympani, as necessarily the curvature of the membrane
must be altered by these rapid variations in the pressure of air. If we
therefore perceive an alteration in the spot of hght during the above-named
manipulations, we can say with certainty that the tube is permeable. But
we can by no means infer the contrary from an absence of change in its
form or size, for often not the slightest motion of the membrana tympani,
even in the normal state, is visible with very rapid and great changes in the
pressare of air, as^ for instance, daring catheterization, while a manometrical
tube, inserted into the meatus, undoubtedly indicates the presence of a change
in the curvature.

Besides this cone of light, there are reflections also at other places on the
membrana tympani in its normal state, especially a faint lustre on the
posterior superior portion, and here and there a small reflection of light
from the short process of the hammer and the depression of Shrapnell's
membrane, also a small band of light on the antero-inf erior periphery of the
membrane, which has been called the sulcus reflex by Bezold, because it
originates in the groove formed between the membrana tympani and the
fold of the sulcus.

The inclination of the membrane in the living subject appears on
inspection to be much less than in the anatomical preparations.
This fact is of great importance in judging the nature of the changes
in the membrane and in operations upon it. Besides, our judgment
as to the inclination of the membrane is often influenced by the
width of the osseous meatus in such a way, that with a wide meatus
the membrane seems to be placed more perpendicularly than with a
narrow meatus.

The curvature of the membrane has also an influence upon our
ability to judge of its pathological state. It varies in diflkrent
individuals in the same manner as the inclination, and our judg>
ment of the degree of curvature from inspection in the living is
also apt to be faulty, as it appears to us less curved inward than it
is in reality.

According to my examinations, the transparency of the membrane
exercises an important influence upon the judgment of its curvature.

Digitized by VjOOQIC

NORMAL STATE OP THE MEMBRANA TYMPANI. 79

The more transparent the membrane, the less it seems curved ; the
more opaque the membrane, the more the funnel-shaped concavity
of the external surface seems to project.

If we take a general survey of the foregoing, the following normal
appearance of the membrana tympani may be seen. At the anterior
superior pole of the membrane (Figs. 69 and 70) there is seen a
whitish projecting spot, the short process of the malletis, from which
there extends backwards, downwards, and towards the centre of the
membrane a whitish or yellowish process, expanding like a spatula
at its inferior extremity, the handle of the malleus. In front of and
below the extremity of the handle there is a triangular spot of light,
the cone of light, with its apex at the umbo and its base directed
forwards and downwards towards the periphery. The portion of the
membrana tympani between the handle of the malleus, the cone of
light, and the anterior wall of the meatus, generally of a darker gray

Fig. 71.— Sieglb's Pneumatic Eab-Speculum.
(Speculnm \ size, baUoon J size.)

than the rest of the membrane, is seldom seen in adults, but is visible
in children in two-thirds of the cases (Bezold) as far as the periphery ;
the portion behind the handle, which is separated from the posterior
superior wall of the meatus by a lightish-coloured line, more or less
pronounced, appears much larger and lighter in its colour, the latter
being modified as above described {v, p. 76).

Pneumatic Speculum. — To the above-mentioned methods of
examining the membrana tympani must be added that with the
pneumatic speculum, a method most important for the diagnosis
of affections of the middle ear, and by the invention of which
Siegle {Deutsche KliniJc, 1864) has won everlasting fame. This
instrument (Fig. 71) differs from the ordinary speculum in having
its outer end closed by an obliquely-inserted plate of glass — ^which
must be inserted as far as possible into the speculum so as to avoid
the disturbing effect of reflected rays of light — and a small nipple
projecting from its side, to which is fastened an india-rubber tube
furnished with a small balloon. By means of an olive-shaped nozzle

Digitized by VjOOQIC

PNEUMATIC SPECULUM.

(Delstanche, Fig. 72), or by putting a small piece of india-rubber
tubing on the nozzle (of which it has three sizes), the instrument
can be hermetically fixed in the external meatus.

To examine the membrane, the speculum, inserted into the meatus, is
fixed with the left hand, so that reflection from the glass plate does not

interfere with the
examination. Then
the membrana tym-
pani is illuminated
by means of the
concave mirror, and
the air in the ex-
ternal meatus is alternately condensed and rarefied
by the balloon, by compressing it slightly with two
fingers of the right hand, quickly releasing it after
each pressure. Condensation of air by blowing into
the speculum with the mouth is unsuitable, as the
inner surface of the glass is dimmed by the con-
densed breath.

In place of the small balloon one can use the
* raref acteur * invented by Charles Delstanche (Fig.
72), which is provided with a double valve. It is
used with the Siegle speculum as well for diagnostic
as therapeutical purposes, and has the advantage,
according to the direction of the stopcock A, of
either alternately condensing and rarefying the air
in the external meatus or of rarefying it only. Its
action is more energetic than the ordinary Single
speottlum, and is able by aspiration to replace an
abnormaUy depressed membrane nearer to its proper
position.

In the normal state, during this method of
examination, considerable movement of the mem-
brana tympani is observed, greatest midway be-
tween the mallens and the periphery. The most
striking sign of movement is the change in the
form of the cone of light, which becomes con-
siderably smaller during condensation. But on
close inspection of the handle of the malleus a very
^^ji distinct movement of it is also visible, for during

l^^l^^^^ condensation either its inferior extremity moves

Ifriw*^^ downwards and inwards, or the whole haifdle moves

in this direction. This mobility of the handle
of the malleus undergoes many changes in disease of the middle ear, being
lost either partially or completely by thickening and inflexibility of the
membmna tympani, or by rigidity and anchylosis of the articulation of the

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METHODS OF EXAlilNATION OP THE MIDDLE EAR. 81

malleus and incoB, or lastly, by abnormal adhesion of the head of the malleus
to the adjacent walls of the tympanic cavity.

As Siegle has mentioned, the pneumatic speculmn is used with
most success in cases where it is required to ascertain whether the
membrana tympani, through thickening of its layers, has decreased
mobility, or through atrophy and formation of cicatrices the
mobility is increased ; and farther, if some of its parts be adherent
to the inner wall of the tympanic cavity. The examination shows
that those portions of the membrane which are united with the
opposite wall of the tympanic cavity remain unmoved during con-
densation and rarefaction of air with this instrument, or make only
slight excursions, while the portions which are not adherent exhibit
a distinct movement.

The changes in the bloodvessels of the membrana tympani and
in the external meatus during this mode of examination is, according
to my observations, of special interest. For if these vessels are
strongly injected, that injection will partly or altogether disappear
during the condensation of air with the pneumatic speculum; as
soon, however, as the condensation of air ceases, the bloodvessels
quickly fill again.

B. Methods of Examination op the Middle Ear.

Among the methods of examination of the organ of hearing, the
various means for examining the state of the Eustachian tube and
of the tympanic cavity hold a prominent place. By their aid we are
often able to obtain information with regard not only to the permea-
bility of the Eustachian tube, but also to the presence of diseased
products in the middle ear, and to the state of the membrana tym-
pani But these methods are of still greater importance in the
treatment of the affections of the middle ear, as they supply us with
the means of conducting therapeutic agents in the form of com-
pressed air, gases, vapours, or fluids into the tympajiic cavity.

These methods are :

a. The Yalsalvan Method.

b. Catheterization of the Eustachian Tube.

c. The Method of the Author, so called Politzer's Method, for

effecting the Permeability of the Eustachian Tube.

Before commencing the description of these methods, it is ad-
visable, with regard to the estimation of their therapeutic value,
to make a few remarks about the mechanical action of compressed
air in diseases of the middle ear.

Digitized by VjOOQIC

82 MECHANICAL ACTION OP INFLATION OP THE TYMPANUM.

On the Mechanical Action of Currents of Air introduced into the
Tympanum in the Diseases of the Middle Ear.

The main purpose of the methods now about to be described is to
effect the permeability of the Eustachian tube for diagnostic pur-
poses, and to conduct compressed air into the middle ear to remove
or lessen the anomalies of tension and the obstacles to the conduction
of sound, which disturb the fimction of hearing.

The first effect of a current of air conducted from the pharynx to
the middle ear is produced in the Eustachian tube, the walls of
which, lying against each other in the normal state, are forced
asunder, and its lumen widened. If the tube is obstructed by
swelling and oedema of its membrane, or by accumulation of
secretion, so that the entrance of the tube cannot be made to gape
by an act of swallowing, the permeability of the canal and the com-
munication between the air in the tympanic cavity and that in the
pharynx are re-established by the introduction of a current of air.
By the action of the current of air that part of the secretion which
is deposited near the pharyngeal orifice is forced into the pharynx^
while that in the superior portion of the tube is forced towards the
tympanic cavity.

The effect of such a current of air upon the Eustachian tube is
by no means momentary or temporary, as many assert, for ex-
perience shows that the constricted tube is often mechanically
dilated by the pressure of the air on its walls, and the tumefaction
of the hypersBmic and swollen mucous membrane is lessened or
quite removed by the action of the air-current, because the blood
is gradually displaced from the dilated vessels.

The current of air which penetrates into the tympanic cavity
through the tube will in the first instance act upon the inner surface
of the flexible membrana tympani, bulging it out towards the lumen
of the external meatus. As we have already seen, the malleus, con-
nected with the membrane, and to a less degree also the incus and
the stapes, will follow this outward movement. Therefore, as in
diseases of the middle ear, the membrana tympani with the ossicular
chain is very often abnormally tightly stretched inwards, and the
propagation of sound thereby much hindered, the membrana tympani
and the ossicula are forced back into their normal position by the
introduction of a current of air, if applied with sufficient force, and
by thus removing the abnormal tension of the sound-conducting
apparatus, its power of vibration is partially or totally re-established.

Indeed, experience shows where hardness of hearing exists in
consequence of the closure of the Eustachian tube and the rare-

Digitized by VjOOQIC

MECHANICAL ACTION OP INFLATION OF THE TYMPANUM. 88

faction of air in the middle ear caused thereby, a striking improve-
ment in the hearing will take place immediately after the propulsion
of air into the middle ear. The abnormal tension of the hearing-
apparatus, which is caused by tightness of the ligaments of the
ossicula, by retraction of the tendon of the tensor tympani and by
newly formed bands of connective tissue, stretched out between the
membrana tympani, the ossicula, and the walls of the tympanic
cavity, is often decreased by the pressure of a strong current of air
in the middle ear, the membrajia tympani and the ossicula moving
outwards, and the tight ligaments and bands being stretched.

The current of air entering into the tympanic cavity exercises
pressure not only upon the inner surface of the membrana tympani,.
but at the same time upon the fenestrsB rotunda and ovalis. If,,
therefore, the tissues closing these fenestrsB have become inflexible
through inflammatory thickening, they will become relaxed and
more mobile by the repeated action of the compressed air, and con-
sequently the waves of sound will be more readily propagated.

Of course the variations in pressure of air in the tympanic cavity
will also have an important influence upon the relative pressure jn
the labyrinth {vide p. 66), for the inflammatory aflections of th&
middle ear are very frequently associated with increased pressure
in the labyrinth, partly in consequence of its two fenestrae being
clogged with exudation, partly in consequence of the abnormally
increased tension of the sound-conducting apparatus, by which the
stapes is pushed in too strongly towards the vestibule. If this-
abnormal tension is removed by a current of air, and the foot-plate
of the stapes is moved outwards, the abnormally increased pressure
in the lab3rrinth, and the subjective noises and disturbances of
hecudng which often accompany it, will be lessened or totally
removed.

The air-douche is also of considerable importance in the removal
of exudation from the middle ear, but the mechanical action of the
compressed air in this instance must be closely examined in regard
tp its eflects upon exudative accumulations both with and without
perforation of the membrana tympani. The view which was formerly
current, viz., that in cases of catarrh of the middle ear unaccom-
panied by perforation of the membrane, the improvement in hearing
following the use of the pneumatic douche was brought about by the
expulsion of the exudation from the tympanic cavity, has been con-
siderably modified by experiments made by me on human ears*
These experiments showed that the larger portion of the secretion^
especially if of a tenacious character, remains in the cavum tympani,
even when a strong current of air is used ; and that the improve-

Digitized by VjOOQIC

84 MECHANICAL ACTION OP INFLATION OF THE TYMPANUM.

ment in hearing which immediately follows the action of the douche
is brought about chiefly by the removal of the abnormal tension in
the tympanic cavity. Fluid exudation in the middle ear is, however,
often partially or completely removed by an inflation of air, if the
head is much inclined forwards and sideways during the operation.
The position of the tube is thus changed, so that the ostium tymp.
tubae is directed exactly upwards, and the ostium pharyngeum exactly
downwards, and thus, when the tube is opened, fluid can gravitate
from the tympanic cavity into the naso-pharynx.

If, then, a cure is effected by the frequent propulsion of air in a
number of cases where the exudation cannot be mechanically
removed by the current, it is simply due to the absorption of the
secretion in consequence of the re-establishment of the normal
pressure of air in the tympanic cavity. For, as already mentioned,
the air is rarefied in the tympanic cavity by the closure of the
Eustachian tube in affections of the middle ear, combined with
swelling and hyper-secretion. Hence the blood and lymphatic
vessels of the mucous membrane of the cavity will be under a
subnormal pressure of air, a condition which is favourable to the
exudation of fluid from the vessels into the tympanic cavity.

I am of the opinion that by propelling air into the tympanic cavity
in these cases, the circulation in the blood and lymphatic vessels
again becomes normal on the re-estabHshment of the normal air-
pressure, and thus the absorption of the secretion is effected. I
formed this opinion from the observation of cases where an acute
inflammation of the middle ear, accompanied by marked injection
and opacity of the membrana tympani, had already lasted for
several weeks or months, and where no increase in the hearing-
distance was observed previous to the treatment. If in such cases
a current of air is conducted into the middle ear, not only will a
considerable improvement in the hearing immediately take place,
but also a noticeable change in the membrana tympani will be
observed during the following days, while the improvement in the
hearing makes still further progress after the repeated introduction
of air. First the injected radiating vessels disappear, and then the
peripheral vascular wreath, the membrane becomes more trans-
parent, its lustre returns, and with the removal of the hardness of
hearing, the membrana tympani has, as a rule, regained its normal
appearance.

It is sufficiently clear from these observations that the exudations
lying in the tympanic cavity in cases of closure of the tube, together
with the abnormally decreased air-pressure, keep up the hyperaemia
in the middle ear, as the dilated vessels on the external surface of

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MECHANICAL ACTION OF INFIiATION OF THE TYMPANUM. 86

the membrana tympani prove. The speedy disappearance of a
hyperemia which has existed for some time, and of hardness of
hearing after air has been injected several times into the tympanic
cavity, demonstrate the favourable effect of the air-douche in bring-
ing about a re-establishment of the circulation in the middle ear
and the absorption of the exudation.

The effect of the propulsion of air into the middle ear with a
perforated membrana tympani is essentially different from the re-
sults hitherto described. For, as the current of air, entering
through the Eustachian tube, escapes through the perforation, the
secretion deposited in the tube and in the tympanic cavity will be
forced immediately through the aperture in the membrane into the
external meatus, and pus and mucus are in this manner removed
from the middle ear. The current of air has the same effect in
cases of exudation in the middle ear, where the membrana tympani
has been artificially perforated. In these cases serum, mucus, or
pus will be forced out of the cavum tympani through the artificial
opening into the external meatus, and the cavum tympani emptied,
as is not possible with an intact membrana tympani.

In cases of perforation of the membrane, the current of air which
is caused to rush through the middle ear and the external meatus is
not without influence on the position of the ossicula, in spite of its
escape through the aperture. Even if the air which rushes through
the Eustachian tube escapes into the external meatus, the current
acts also at the same time upon the internal surface of the remnant
of the membrane, and forces it and the ossicula outward into an
approximately normal position.

The view that, in perforative inflanunation of the middle ear, pustular
secretion in the middle ear is forced into the mastoid cells by the air-douche,
has been disproved by Michel {A. /. 0., vol. xi.), who proved that the
secretion is always forced into the external meatus.

a. The Valsalvan Method,

The Valsalvan method consists in condensing the air in the
naso-pharynx by a strong act of expiration, performed with closed
mouth and nostrils. By this means the walls of the Eustachian
tube are forced asunder, and the condensed air is propelled into the
t3rmpanic cavity.

In the first place, it is important to mention that the mano-
metrioal pressure effected by the Valsalvan method varies accord-
ing to the age of the individual, and according to the individual
power of the expiratory muscles. Hence the pressure will be far

Digitized by VjOOQIC

86 THE VAL8ALVAN METHOD.

less in children than in adults, and also considerably less in weakly
than in robust individuals. Waldenburg's experiments prove also
that there is considerable difference in the amount of the expiratory
pressure in the two sexes, as in males it amounts on an average to
100-130 mm., in females to 70-110 mm., as indicated by the quick-
silver column.

During the execution of the Valsalvan method the obstructions
opposed to the entrance of air into the tympanum of a normal
ear are situated partly in the Eustachian tube, partly in the mem-
brana tympani. Since the walls of the Eustachian tube are closely
approximated to each other, but to a different degree in different
individuals, the expiratory pressure necessary to force the air into
the tympanic cavity must consequently be greater the closer the
walls of the tube are in contact, whilst the muscles of the tube are
at rest. The membrana tympani itself forms no small hindrance to
the current of air, and the pressure which is required to overcome
its tension and to bulge it outwards towards the meatus, is not
inconsiderable. According to Hartmann, a pressure of, on an
average, 20-40 mm. Hg. suffices to force the air into the tympanic
cavity under normal conditions.

The entrance of air into the tympanic cavity during the Valsalvan
method can be proved by inspection of the membrana tympani
as well as by auscultation. If the membrane of a normal ear be
inspected during the Valsalvan method, an outward curvature of
the portions situated between the hcmdle of the malleus and the
periphery will be seen. The change in the form of the cone of light
will specially attract attention, as a rule it is shortened and
narrowed, and in some rare cases even disappears (Moos). A sUght
excursion of the lower end of the handle of the malleus forward and
outward occasionally occurs. Often no movement of the membrana
tympani occurs during the use of Valsalva's method.

The air which penetrates into the tympanic cavity produces a
noise in the middle ear, which can be perceived either by placing
the auricle immediately to the concha of the person Jbeing examined,
or in a more practical manner by the auscultation tube (Otoscope ;
V, Catheterization of the Eustachian Tube) designed by Toynbee.

This short, puffing sound, which is often preceded by a slight
murmur caused by the friction of the air in the Eustachian tube,
is generally called the sound of the concussion of the air on the
membrana tympani, and is produced by the rapid outward move-
ment of the portions of the membrane situated between the handle
of the malleus and the periphery, as I have ascertained by numerous
experiments made on fresh ear specimens. The sound is therefore

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THE VALSALYAK MBTHOD. 87

caused by the movement of the membrane itself, and not by the
concussion of the air, and it should for this reason be more cor-
rectly described as the sound caused by the bulging out of the
membrane.

While the Valsalvan method often fails to effect the entrance of
air into the middle ear in normal ears, it does so still more
frequently in abnormal ones. Hartmann found that with a slight
swelling of the mucous membrane of the Eustachian tube, with no
disturbance of hearing, as often occurs with naso-pharyngeal catarrhs,
the manometrical pressure was increased to 100-120 before the
Valsalvan method was successful. A still more considerable in-
crease in the pressure is required in cases of disease, especially in
the affections of the middle ear accompanied by swelling and secre-
tion. As they are generally combined with a tumid state of the
mucous membrane of the tube, and therefore with stricture of the
isthmus tubsB, such an obstruction to the entering current of air is
offered that it is often impossible to overcome it by the greatest
expiratory pressure.

This is especially the case in that group of affections of the
middle ear which run their course without perforation of the mem-
brana t3anpani. In this group obstructions besides those in the
Eustachian tube, as swelling, plugging with mucus and crusts, and
connective-tissue strictures, such other obstructions as accumulated
secretion in the middle ear, great tension of the membrana tympani,
and a greater adhesion of the walls of the Eustachian tube, caused
by the rarefaction of air in the cavum tympani, increase the diffi-
culty of forcing air into the middle ear. It must be mentioned,
however, that in certain rare cases in which a notably greater
pressure is brought to bear, eg,, as in catheterization, or in my
method, air cannot be forced into the middle ear, or only with great
difficulty, the Valsalvan method is nevertheless successful.

However, in that group of the affections of the middle ear where
the membrana tympani is perforated, the Valsalvan method may
be much more frequently used as a means of diagnosis. For here
the resistance of the membrane has ceased; a counter-opening
has been made into the tympanic cavity, which considerably
facilitates the entrance of a current of air through the tube into the
tympanum. Although in many cases of perforation of the mem-
brana tympani the exit of the air through the meatus, during the
Valsalvan method, is accompanied by a perceptible sound, it must
not be inferred from the absence of the hissing noise that the
membrana tympani is not perforated, because extensive swelling of
the mucous membrane of the tube, granulations and inspissated

Digitized by VjOOQIC

88 THE VALSALVAN BCETHOD.

secretion in the cavum t3rmpani and external meatus, may hinder
the entrance of the air into the middle ear.

To sum up, it will be found that the Valsalvan method as a
means of diagnosis is certainly of limited value, but, nevertheless, it
can be used in a great nimiber of cases. If it gives a positive result,
we may, generally speaking, infer that the mechanical obstruction
in the Eustachian tube is slight ; if, however, it give a negative
result, we may assume that, the membrana tympani being intact, or
even perforated, a greater obstacle exists in the Eustachian tube or
elsewhere in the middle ear. From my experience, these results
are of no slight importance in prognosis, for in inflammations of the
middle ear, accompanied by swelling and secretion, the prognosis in
regard to speedy removal of the pathological changes will, on the
whole, be more favourable in those cases where the permeabiUty of
the tube can be effected by the Valsalvan method, than in those
in which the application of the catheter or of my method is neces-
sary. The examination of the middle ear should therefore always
be commenced with the Valsalvan method, to be followed by my
method and by catheterization.

The therapeutic value of the Valsalvan method will be discussed in the
division in which the effects of the methods enumerated at the commence-
ment of this division are compared.

A method caJled Toynbee's experiment remains to be mentioned. It
consists in performing the act of swallowing with closed nostrils, whereby a
feeling of fulness in the ears arises, which was erroneously attributed by
Toynbee to condensation of the air in the middle ear (compare p. 68). This
experiment is, however, of but small value, because the cracking sound
which should thereby be heard in the normal ear, is often imperceptible, but
is perfectly audible in pathological cases in which the tube is impermeable.
Equally unreliable is the experiment for purposes of inspection, because
where the ear is healthy every evidence of the movement of the membrane
may be wanting, whereas in cases in which the Eustachian tube is im-
permeable, movements of the membrane may be perceived.

b. Catheterization of the Eustachian Tube,

Catheterization of the Eustachian tube consists in the introduction
of a Eustachian catheter through the nose, or more rarely through
the mouth, into the tube. This is one of the most important
operations performed in the diseases of the ear. For not only does
the catheter give more reliable information as to the state of the
middle ear than the other methods of examination, but it is also
quite indispensable as a means of conducting gaseous or fluid agents
into the middle ear for remedial purposes.

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THE PHARYNQEAL OBIFICB OF THE EUSTACHIAN TUBE. 89

In consideration of the importance of this subject we will describe
the anatomical relations of the naso-pharynx, which have to be
considered during catheterism, before entering on the details of the
method.*

1. Topographical Relations of the Pharyngeal Orifice of the
Eustachian Tube.

The pharyngeal orifice of the Eustachian tube (Fig. 78, h) is situated on
the lateral wall of the pharynx, at a level with the horizontal prolongation of
the inferior turbinated bone. It presents an oval depression, pointing obliquely
downwards, which is bordered in front by an ill-defined swelling, above and
behind, however, by a strong, firm lip, projecting towards the pharynx.

The anterior lip is separated from the lateral wall of the nose by the sulcus
nasalis posterior. An extensive fold, the phca salpingo-pharyngea, extends
from the posterior lip of the tube to the superior portion of the arcus palate-
pharyngeus.

Between the posterior hp and the posterior wall of the pharynx there is a
depression, BosenmfiUer^s fossa (^), which is rich in glandular tissue, and
subject to great individual variations in size. In consequence of chronic
pharyngeal catarrh, a cystic hypertrophy of the closed mucous glands, their
amalgamation with the originally existing depressions of the mucous mem-
brane in this place, and formation of extensive gaps and bridge-like bands
often occur, by which the operation of catheterization is sometimes rendered
difficult, especially when the operator allowa the beak of the catheter to
become entangled in these bands.

The distance of the orifice of the tube from the posterior pharyngeal wall
will, therefore, not only vary in different individuals (according to L. Mayer
it amounts on an average to 1'8 cm.), but it will also depend on the degree
of swelling of the mucous membrane of the pharynx. For this reason it is
impossible to employ the distance between the orifice of the tube and the
posterior wall of the pharynx as a safe guide in the introduction of the
catheter.

Below the orifice of the tube is the veliun palati («), which in the living
arches upwards above the level of the hard palate. The muscles which enter
it from the tube and from the palatine arches give to it a considerable degree
of mobility, tension, and power of resistance. Every movement of the velum
palati has associated with it a movement in the Eustachian tube, and the
posterior extremity of a catheter undergoes a perceptible change of position
at every motion of the soft palate, if the catheter either comes into contact
with the velum or be introduced into the tube.

* The invention of catheterizing the tubaa Eustachia was first described bj a
postmaster named Gayot in a report sent to the Paris Academy in 1724, in which he
gave an account of his own cure by the means of a tube introduced into the Eustachian
tube through the mouth. The catheterization through the nose was first done by
Archibald Gleland, but according to the French by Petit. The diagnostic and
then^utio worth was fiist proved by Saissy, Itard, and Deleau, later by Knh,
Kramer, Cerutti, and v. Troltsch, who firot gave the positive indications for its use.

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THE PHARYNGEAL ORIFICE OF THE EUSTACHIAN TUBE.

In the nasal cavity, lying in front of the Eustachian tube, the three
turbinated bones on the outer wall and the nasal septum merit description.
The superior tiu-binated bone (c) is short and narrow, while the middle (6),
and especially the inferior (a) turbinated bones, project more into the nasal
cavity. Hence there arise below these cmrved bones the three nasal
meatuses, of which the lower, according to Woakes a prolongation of the
Eustachian tube to the nasal orifice, is of special importance in catheteriza-
tion.

In the performance of catheterization of the Eustachian tube,
besides the obstacles produced by pathological processes which will

Fio. 73. — Vebtioal Sbotion of the Naso-phabtnx with the Cathkteb imtso-

DUOED into the EUSTACHIAN TUBX.

a. Inferior turbinated bone ; b, Middle turbinated bone ; c, Superior turbinated
bone ; d. Hard palate ; e, Velum palati ; /, Posterior pharyngeal wall ; g, Rosen-
mtiller's cavity ; h, Posterior lip of the orifice of the Eustachian tube.

be described later on, there have to be considered the frequent con-
genital deformities of the nasal septum and of the turbinated bones.
For if a considerable collection of crania be examined, it will be
found that the septum of the nose seldom represents a perpendicular
plane, but that it is more or less bulged out, sometimes to one side
and sometimes to the other (more frequently towards the left side),
by which one half of the nose is greatly narrowed, while the other

Digitized by VjOOQIC

CHOICE OF CATHETER. 91

iB proportionately more spacious.* By excessive development of the
middle, but more often of the inferior, turbinated bone, the permea-
bility of the nose is often impaired, and the contraction will reach
a higher degree if an enlargement of the turbinated bones is com-
bined with a bulging out of the nasal septum towards the same side.
The distance of the orifice of the Eustachian tube from the pos-
terior nares is as variable as from the posterior pharyngeal wall.
Not only is it generally less in the female than in the male, but
great fluctuations occur with variations in the cranial formation — e.g.,
in prognathous people it is mostly greater than in orthognathous ;
therefore the distance from the entrance of the nose to the orifice of
the tube cannot be used as a guide in catheterization.

2. Choice of Catheter,

For catheterization I almost invariably use instruments made of vulcanite,
as first proposed by me (Fig. 74). Their length is 18-16 cm.,t the length of
the beak being 2-2^^ cm., with a curvature of 145'. A metal ring fixed to the
posterior widened extremity corresponds with the concavity of the curvature
of the beak, and serves to indicate the direction of the point of the catheter
when the instrument is in the naso-pharynx. The unpleasant sensation
caused by the contact of the metal instrument with the mucous membrane is
not felt when these catheters are used ; and, indeed, experience shows that
patients almost without exception prefer the treatment with the vulcanite
catheter to that with the metal instnunent, a fact which is not to be under-
valued in practice. The metal catheters also cause pain by pressure upon
the inflexible walls of the nasal passages, while the vulcanite ones more easily
foUow the curvatures of the nasal cavity on account of their elasticity. This
moderate degree of elasticity, however, by no means impairs the fimmess of
the instrument, which is required in order to feel the sliding of its beak over
the posterior lip of the tube, or the resistance at the posterior margin of the
nasal septum.

The objection that vulcanite catheters might easily be broken in meeting
obstacles in the nose, is met by the fact that forced catheterism is inadmissible
in cases of stricture in the nasal cavity.

The selection of the proper sized catheter is of great importance in prac-
tice. I use catheters of ioxa sizes, of which the diameter of the thickest
(No. 4) is 8J mm., the next (No. 8) 8 mm., the mediiun size, which is the
most used (No. 2), 2^ mm., and the thinnest (No. 1) 1^ mm. ; the thickness
of the catheter waJl measmres ^ mm. The catheters which I have lately
brought into practice, with an oval opening at the smaller end, have the advan-
tage that the oval point of the catheter fits more closely into the slit-like

* Thiele {Zeitschrift /. rat, Med., voL vL) found that in 88 out of 117 akulls the
septum WM bent.

t The shorter catheters proposed by Lues have certainly the advantage that they
offer less resistance to the air passing through them, but those made of vulcanite do
Bot possess the same amount of flexibility as the longer ones.

Digitized by VjOOQIC

92 CHOICE OF CATHETEB.

' aperture of the tube, so that air and fluids can be injected
into the middje ear with more force than with the round
pointed ones. The long direction of the oval opening is on
an axis with the curvature of the catheter.

The average curvatiure of the catheter, as given above, of
145°, is not proper for all cases. Where there are larger
obstructions in the nasal and post-nasal cavities, w^oh in-
crease the difficulty of introducing and turning a normally
curved catheter, it is necessary to change the angle of cm:-
vature, either by warming over an alcohol flame or dipping
in warm water. The therapeutic action of such flat curved
catheters is much less, as the point cannot be introduced far
enough into the Eustachian tube.

On the other hand, it is necessary occasionally to use
catheters with a long and strongly-ciu*ved beak. These
catheters are used only in such cases where by the use of
normaJly-curved catheters, the Eustachian tube cannot be
made pervious, or where one wishes to inject a large quantity
of fluid into the middle ear. Air and fluid can be injected
so much more surely through the narrowest part of the tube
into the caviun tympani, the deeper the point of the catheter
penetrates the tube.

The possibility of inoculation with syphilis by means of the
catheter, a fact which was first established in Paris, necessi-
tates the greatest care in using these instruments. In my
own practice a special instrument is reserved for each patient
during the whole course of treatment, a precaution which
every practitioner is bound to observe, not only for the
absolute safety of the patient, but also to abohsh any possible
fear of infection on the part of the patient. Doctors with a
small practice, who only have a limited number of instru-
ments at their disposal, should invariably cleanse the instru-
ments themselves. Directly after the use of the catheter, it
should be placed in a solution of corrosive sublimate (1 : 1000),
from which it should not be removed until the following day,
when, in addition to being washed in warm water and
thoroughly syringed out, the beak should be carefully wiped
out with a piece of fine linen. Instruments which have been
used on persons well known to be infected must on no
account be uf>ed again.

3. Method of Catheterizing the Etistachian Tube.

Of the numerous methods which have been recom-
mended for the performance of catheterization, two
canite'cath- specially deserve a detailed description because in

ETKB OF Mb- carrying them out fixed anatomical relations serve as
DiuM Thiok-

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METHOD OP CATHETERIZINQ THE EUSTACHIAN TUBE. 93

guides for the introduction of the catheter intd the tube, and
because they have proved, from experience gained in practical
classes, not only to be safest, but also to supplement one
another. The anatomical guides in question are the posterior lip
of the tube together with the rigidly extended plica-salpingo-
pharyngea and the posterior margin of the septum of the nose.

Catheterization of the Eustachian tube, in order to avoid painful
sensation to the patient, must be performed with the greatest care.
It is my opinion that the operation should be carried out in the
sitting position. Patient and surgeon should be so placed that the
table, on which the necessary instruments are placed, is to the right
of the surgeon. It will be found as well to use a high-backed chair
80 that the patient's head may not slip too far backwards during the
operation. To introduce the catheter with as little tmpleasantness
as possible to the patient, the point of the nose is first tilted up with
the thumb of the left hand, and the head is steadied by placing the
other four fingers against the forehead. Then the posterior ex-
tremity of the catheter is taken between the thumb, forefinger, and
middle finger of the right hand like a pen, and is slightly depressed
while the beak is introduced into the nasal cavity.

The point of the beak is now lowered to the floor of the nasal
cavity, the posterior extremity of the catheter being lifted up tmtil the
instrument is in a horizontal position ; it is then moved backwards,
the beak being constantly in contact with the nasal floor. In a
normal nasal cavity the catheter passes between the turbinated
bones and the nasal septum (more rarely in the space formed by the
inferior turbinated bone) backwards along the osseous floor, vrithout
noticeable change in the direction of its beak, and then glides across
the superior surface of the soft palate to the posterior wall of the
pharynx. During all these manipulations the catheter must be held
as loosely as possible in the fingers, so that its beak may easily glide
over any obstruction and the patient be spared unnecessary pain.

By that method in which the posterior lip of the tube serves as an
anatomical guide, as soon as the catheter has reached the posterior
wall of the pharynx its beak is turned outwards and slightly forced
into Bosenmiiller's fossa. While its posterior extremity is some-
what raised, the catheter is retracted with moderate rapidity, during
which movement the beak of the catheter will be felt to sHp over
the bulging lip of the tube, projecting from the lateral wall of the
pharynx.

After the point of the catheter has thus passed the posterior lip,
it has arrived at the pharyngeal orifice of the Eustachian tube. To
insert the beak into the tube it is now sufficient to turn the instru-

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94 [ BIETHOD OF CATHETERIZING THE EUSTACHIAN TUBE.

ment so far outwards, that the metal ring fastened to its posterior
extremity is pointed towards the outer canthus of the eye of the
same side. This direction of the beak corresponds as a rule with
the axis of the Eustachian tube. This method which, according to
Ph. H. Wolf (Lincke, vol. iii., p. 360) was first proposed by Kuh,
is described as Bonnafont's or Kramer's method, and I consider it,
in spite of the opposite view held by Schwartze {L c, p. 25)
together with Lowenberg's method, to be the safest for the general
practitioner.

By the second method, given by Lowenberg, the posterior edge of
the septum is used as the anatomical guide.

After the catheter has been introduced, exactly as in the previ-

/f"*^'

Fio. 75.— Fixing of thi Cathktsr intboduobd into thi Eustachian Tubi

WITH THB LbKT HaND.

ously described method, as far as the posterior wall of the pharynx,
its point is not turned outwards, as in the former method, but
inwards, towards the orifice of the other Eustachian tube, and is
brought into a horizontal position, as ascertained by the position
of the metal ring on its end. The outer end of the catheter is then
moved slightly outwards, and gradually drawn back until the beak
has reached the posterior margin of the nasal septum. During
moderate traction a noticeable resistance will be felt at this place,
which prevents the catheter from being drawn further back, because
its hoop-shaped, curved beak grasps the posterior margin of the
nasal septum. Drawing the catheter too strongly against this
moderate resistance is apt to interfere with the success of this
method. The catheter is now moved towards the septum of the
nose, taken hold of with the left forefinger and thumb close to the
point of the nose, and its beak rotated downwards, and the instru-
ment turned on its long axis more than 180''. The point of the

Digitized by VjOOQIC

METHOD OF CATHETEBIZING THE EUSTACHIAN TX7BE. 95

beak is inserted in this manner into the pharyngeal orifice of the
Eustachian tnbe, provided that the catheter during the last rotation
was not displaced either forwards or backwards, and that no de-
formities exist in the posterior portion of the naso-pharynx or near
the orifice of the tube. Sometimes the tightly stretched velum
palati offers great resistance to the rotation of the catheter down-
wards, whereby the point of the instrument is forced backwards,
and its introduction into the orifice of the tube is prevented. If the
point of the catheter has entered the orifice, the instrument is
brought into the proper position and fixed exactly as in the previous
method. After the catheter has been introduced into the tube, a
fact which can be demonstrated either by auscultation while air is

FlO, 76.~D£L8TAKCHE*8 NOBE ClAMP.

being forced through it, or by pharyngoscopy, the instrument is
seized close in front of the nose with the left thumb and forefinger,
and to fix it firmly in this position the other three fingers of the left
hand are laid upon the bridge of the nose (Fig. 75).

Only when the catheter has to remain for a considerable time
in the Eustachian tube for the introduction of vapours into the
middle ear, do I make use of Dr. Ch. Delstanche's simple and effective
nose-clamp (Fig. 76) to hold the instrument in position. This nose-
olamp consists of a whalebone rod which, after being dipped in hot
water, is bent into an M shape so that the large cruraB squeeze the
alsB of the nose together and fix the catheter. This instrument
renders the complicated and unpleasant instruments of Kramer,
Bau, and Bonnafont useless.

In drawing a comparison as to the value of the respective methods,
it must be borne in mind that Bonnafont's method is specially

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96 METHOD OF CATHETEBIZINQ THE EUSTACHIAN TUBE.

unsuited for such cases as have the posterior lip of the tube flat-
tened or levelled either by ulceration, by cicatricial formation on the
lateral pharyngeal wall, by the atrophy of old age, or by shrivelling
in consequence of chronic catarrh, or where through abnormality of
the turbinateds and septum the point of the catheter cannot be brought
close enough to the side of the pharynx. The application of this
method is just as difficult if great oedema of the posterior pharynx
or the existence of granulations and adenoid growths in that cavity
oflfer obstacles to the finding of the posterior lip of the tube.

In such cases our object will be effected more quickly and safely
by the Lowenberg method. This procedure, which has been made
use of by Prank and Lowenberg, except in some rare cases,*
I have found to be an excellent and generally applicable method,
and the necessary skill for its execution is much more readily
acquired than for other methods. But, on the other hand, it must
not be forgotten that it is impossible in many cases, with a normal
state of the naso-pharynx as well as with obstructions in its pos-
terior portion, to introduce the catheter into the Eustachian tube
by this method, while it is eflfected without the least difficulty by
the first-described procedure. The value of these two methods lies
principally in the fact that in many cases one supplements the other.

In the largely \ised method of Kramer, according to the description of
V. Troltsch {I, c, p. 202}) , the catheter, piished forward to the posterior
pharyngeal wall, is drawn back 2-8| cm. (}•! inch), and its beak, directed
downwards, is then rotated outwards and upwards through an angle of 185°,
whereby it is supposed to enter the orifice of the tube. But here all ana-
tomical guidance for the finding of the orifice is wanting, and the inefficiency
of this method is best characterized by the assertion of v. Troltsch, that the
instrument is often drawn back either too for or too little, in which latter
case Bosenmtiller*s cavity instead of the Eustachian tube will be reached.

In case of great irritability of the soft palate and of the mucous membrane
of the pharynx, catheterization after the above methods often produces spas-
modic coughing and vomiting, which impede the execution of the operation.
The following method can here be recommended as the most useful. The
catheter, introduced into the nasal cavity, and sliding with its point over the
base, is gradually turned outwards, before it leaves the hard palate, in such
a manner that the metal ring at the posterior extremity is placed in an
oblique position, directed outwards and downwards. If in this position the
instrument is pushed backwards, its point, without touching the soft palate,
will enter the orifice of the tube, while the posterior lip of the tube prevents
the instrument from reaching Bosenm&ller's cavity (Triquet). I apply this

* Zur Technik des CcUheteri&mas der Ohrtrompete, Wiener Med, Presae, 1872.

t This diSer* from the description in Kramer's Die Erkenntniw und Beiiung der
OhrenkrankhetUn^ 1849, p. 484, in so far m in it mention ia also made of the tliding
oyer the lip of the tube.

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MISTAKES IN OATHETEBIZATION. 97

modification very often in a quite normal state of the naso-pharynx. The
method of Boyer and Gairal, by which the catheter after passing through the
nose is turned 90° outwards and then pushed backward on a line outwards
and upwards until its point reaches the ostium tubse, can only be recom-
mended for experts.

Lastly, we will mention another modification of catheterization, which some
years ago was asserted to be a new one, but which had already been described
in old works (Lincke, vol. iii., p. 859, and Bau, p. 117). It consists of
drawing back the catheter with its point directed downwards, after the
instrument has been pushed forward to the posterior pharyngeal wall, until
it meets with resistance at the palate, when by a quarter turn the catheter
is supposed to enter the orifice of the tube. With this modification, just
as with any other method, it will be often possible to perform catheterization
after long practice, but it does not afford the same certainty to the less
experienced surgeon as the first-described methods, because the position of
the soft palate varies very much, and because it often yields more or less to
the pressure of the beak of the catheter.

4. Mistakes in Catheterization,
Of the mistakes which may happen even under normal conditions, and
which prevent the success of the operation may be mentioned :

1. The point of the catheter is not laid upon the floor of the nasal cavity
during its introduction, but pushed towards the upper portion of the nose ;
the instrument will then, as a rule, enter the middle nasal meatus, and
be detained there, so that the beak cannot be turned towards the pharyngeal
orifice.

2. The catheter is correctly pushed forward to «the posterior wall of the
pharynx, but the outer extremity of the instrmnent is not tilted up suf-
ficiently ; in this way the point of the catheter, instead of shpping over the
lip of the tube, passes above its pharyngeal orifice.

8. The point of the catheter is in BosenmuUer^s cavity, but while
drawing it back, the posterior lip of the tube offers such a great resistance,
that it may lead to the belief that the instrument is detained in the tube.

4. The beak of the catheter is drawn over the posterior lip of the tube, but
instead of performing the rotation of the instrument, which is necessary for
its entrance into the tube, immediately after the point has sUd over the lip,
it is drawn still farther outwards. In this case the point of the catheter is
often detained by the protuberance at the posterior extremity of the inferior
turbinated bone, which may also give rise to the erroneous assumption that
the instnmaent is detained in the Eustachian tube.

5. The instrument, on being drawn back^ is turned too little towards the
Eustachian tube after it has passed its posterior lip, so that the point is in
the orifice, but the direction of the beak does not correspond with that of
the tube. It may also happen that the catheter, if its beak has not pene-
trated sufficiently far into the canal, slips out again by its being turned too
much outwards and upwards. The point of the instrument is then directed
towards the superior pharyngeal waJl, which can be seen by the vertical
position of the metal ring at its outer end.

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98 MODIFICATIONS OF CATHBTBRIZATION.

5. Modifications of Catheterization in Cases of Congenital or
Pathological Obstacles in the Naso-Pha/rynx,

Besides the congenital anomalies which impede the introduction
of the catheter, or even make it impossible, obstacles in the naso-
pharynx are often met with, due to diseased conditions. The most
prominent are the following : The deformities due to traumatic
affections of the septum of the nose and of the turbinated bones ;
strictures of the nasal cavity from ulceration and caries ; hyper-
ostosis of the upper jaw (Moos) ; polypous formations ; cancer ; sar-
coma, and adenoid vegetations in the naso-pharynx ; and lastly,
often excessive swelling and relaxation of the mucous membrane
of the naso-pharynx.

The possibility of introducing the catheter into the Eustachian
tube in the presence of such anomalies depends in the first place
on the degree of the stricture in the nasal cavity. If, during the intro-
duction of a thick catheter into the nasal cavity, an obstacle is
encountered which cannot be overcome by turning the instrument
slightly to the side, a smaller catheter must be employed. If this
also cannot be pushed forward, the operation must be attempted
with a catheter, the beak of which is less curved. Arrived at the
place of obstruction, it is not at all advisable to press the instrument
forward by force, as not only is unnecessary pain caused, but the
nasal walls may also be injured. To evade the obstacle, it is better
to turn the beak of the catheter outwards (more rarely inwards)
when arrived at the point of obstruction, and at the same time to
push the instrument gently backwards. During this manipulation
the catheter will often execute a complete rotation round its axis ;
indeed, cases frequently occur where two rotations of the instrument
are necessary to effect a passage through a nose obstructed at
several points, and to reach the posterior pharynx. If the obstruc-
tion is in the anterior portion of the nose, it can easily be discovered
by lifting up the tip of the nose with the left thumb, and by illu-
minating with the concave mirror first one side of the nose and then
the other. It will then often be perceived that the septum of the
nose, bulged out strongly at one side, is in contact with the tur-
binated bones. Tumours and polypoid growths in the anterior and
middle portions of the nasal cavity can often also be seen from the
front by this illumination. In cases, however, where the narrowing
is situated in the deeper portions which cannot be immediately
viewed, information regarding the cause and extent of the obstacle
may be obtained by Zaufal's specula, by the rhinoscope, or by
digital examination.

In case of absolute impermeability of one of the sides of the nose.

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MODIFICATIONS OF CATHETERIZATION. 99

it has been recommended to effect catheterization of the corresponding
Eustachian tube from the other nasal meatus ; and where both sides
are impermeable, from the cavity of the mouth. These modifica-
tions of catheterism can be quite dispensed with in many cases since
the invention of my method, as by this procedure almost the same
result is obtained as by catheterization. The above modifications will
therefore be used only in exceptional cases where the permeability
of the Eustachian tube can be effected neither by the Valsalvan
experiment nor by my method, or where the injection of fluids into
the middle ear or the introduction of bougies into the Eustachian
tube are advisable.

Gatheterizing the Eustachian tube from the opposite nasal passage,
which was first proposed by Deleau {Bevue Medicate, 1827), and
which is described by Curetti* as a generally applicable method
to save the patient the unpleasantness of the introduction of the
catheter through both nasal passages, may, in the case of a narrow
pharynx, be performed with an ordinary instrument, but can, as a
rule, only be accomplished by using a catheter with a beckk of from
20-25 mm. in length.! The method of procedure is as follows:
After the catheter has been carried forward to the posterior wall
of the pharynx, as in catheterizing the same side, its point is turned
towards the opposite Bosenmiiller*s fossa whereby the metal ring
at the posterior end of the catheter assumes a horizontal position.

The point of the catheter is then pushed into Eosenmiiller's cavity
by drawing the outer extremity of the instrument away from the
septtmi of the nose towards the external wall of the nasal cavity ; it
is conducted into the orifice of the tube by traction over the hard
lip of the tube, and is then pushed into the Eustachian canal by a
moderate movement backwards.

Fixing the instrument in position, in case of catheterism from the
opposite side, is 'also accompUshed most easily with the thumb and
forefinger of the left hand, the other fingers being laid upon the
bridge of the nose.

The indications for catheterization from the cavity of the mouth, which has
been recommended by Stork, Pomeroy, and Eessel, are still more rare than
those for the above modification. This operation is only performed when
both nasal canals are impermeable to the catheter, or when with impermea-
bility of the one canal catheterization from the other side is not possible. I
also use this modification in cases of deficiency of the hard and soft palate,

'"* Nuova asservcKwne di Cateterismo delta tvba Eust, destra dalla narice opposta,
Cfaz. med, italiana StcUi Sardi, 1858.

f The TQlcanite catheters can be made yeiy soft by warming them over a flame or
in hot water for a few seoonds, and they get hard again so quickly, that the beak of
the instrument can be lengthened or curved at wiU in a very short time— a consider-
able advantage in comparison with the stiff inflexible metal instruments.

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100 MODIFICATIONS OF CATHETERIZATION.

whether the orifice of the tube is visible through the gap or not. As the
destructive processes in the palate are mostly combined with ulcerations and
deformities in the nasal cavity, the tube will generally more easily be reached
from the cavity of the mouth through the gap in the palate than through the nose.

The catheters used for this modification are of somewhat thicker calibre.
The ordinary curvature of the beak will generally suffice in case of a defect
in the palate ; with an intact palate the introduction of the tube is effected
by placing the catheter flat upon the tongue (which is at the same time
pressed down by the instrument), carrying it to the posterior pharyngeal
wall and then turning its point upwards and towards BosenmUller*s cavity
on the lateral wall of the pharynx. The instrument is at this stage with-
drawn till its point arrives at the orifice of the tube, which event is recognised
by its being felt to glide over the posterior lip. By a slight movement for-
wards the beak of the catheter is forced into the Eustachian canal. In those
cases in which that fold of the posterior lip of the tube which runs down-
wards can be seen, the point of the catheter may be carried to the ostiiun
pharyng. tubsB by simply pressing it in front of that fold.

In irritable conditions of the pharynx catheterization per os is not only
impeded but even rendered quite impossible on account of the continued
choking and vomiting. In such cases the operation is rendered easier by
painting the velum palati and the base of the tongue with a 6 per cent, solu-
tion of cocaine muriat.

In spite of the frequent congenital or acquired anomalies in the naso-
pharynx, the cases where catheterization through the nose is absolutely imprac-
ticable, in consequence of mechanical obstructions, are on the whole rare.
The insuperable difficulties which occur sometimes in the execution of this
operation, even with a normal condition of the nasopharynx, are much more
frequently due to other causes. This is especially true of children, by whom
it is almost always energetically withstood. But resistance is met with in the
adult also, for not only nervous and old persons but even strong men have an
obstinate aversion to this operation, against which all the remonstrances of the
surgeon are often powerless. Continued f everishness, weakness, and irritability
during the convalescence of sick people of course con tra-indicate catheterization.

We will lastly point out a nmnber of unpleasant incidents which may
occur during the execution of catheterization, and render success either very
difficult or impossible. These are mostly vomiting and a sense of choking
in the throat, which occur when the soft palate is touched, but which subside
as soon as the catheter is introduced into the Eustachian tube. It happens,
however, not unfrequently, that even with the catheter in correct position in
the tube, an attack of vomiting is excited; this occurs especiaUy on each
occasion that air or fluid is injected into the tympanum. Such choking sen-
sations are most commonly met with in old people, who on the whole do not
stand catheterization well, and often do not permit it to be repeated. The rarer
incidents by which the operation is interrupted are : dizziness, fainting, con-
tinuous sneezing, which ceases only after the removal of the instrument,
convulsive attacks of coughing during the introduction of the beak of the
catheter into the Eustachian tube, and bleeding from the nose, which occurs,
even though the catheter is carefuUy introduced, in persons predisposed to it.

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PBOPELLING AIR INTO THE MIDDLE EAR BY THE CATHETER, 101

6. Methods of Propelling Air into the Middle Ear by the Catheter
for Diagnostic and Therapeutic Purposes,

To Deleau is due the credit of first having made extensive use of
this procedure for purposes of diagnosis, but principally in the treat-
ment of the diseases of the ear. He utilized the results of Laennec's
investigations, and, applying them practically, made an important
advance in the treatment of ear-diseases.

For the purpose of propelling air into the middle ear, a pyriform
india-rubber balloon (capable of holding 360-420 grammes of fluid) is
generally used, a force-pump being rarely employed. The air-douche
by means of the balloon is executed in the following manner : After
the catheter, which has been introduced into the Eustachian tube,
is fixed with the fingers of the left hand, and the corresponding ear

/f^-

FlO. 77. — AlB-DOUOHE WITH THB InDIA-BUBBBB BaLLOON.

of the pafcient has been connected with that of the surgeon by means
of the auscultation-tube,* the india-rubber balloon is seized with
the right hand in the manner represented in Fig. 77, and is inserted
into the outer extremity of the catheter, which fits it exactly, and
the air is propelled into the middle ear by compression.

The following precautions have to be observed : The first com-
pressions of the balloon must not be made too rapidly nor with too
much force, as should the point of the catheter happen to be pressed
against the walls of the pharynx or of the tube, the mucous mem-
brane is injured by a too powerful current of air. The air then
penetrates into the cellular tissue of the pharyngeal mucous mem-
brane, and an emphysema results which is mostly confined to the

* This ooDBistB of an india-rubber tube about 70 cm. long, to the ends of which are
fastened two olive-shaped perforated tips.

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102 PROPELLING AIR INTO THE MIDDLE EAR BY THE CATHETER.

pharynx, but sometimes also extends to the entrance into the larynx,
as well as to the submucous connective tissue of the lateral region
of the neck and face.

The submucous emphysema in the pharynx, which is mostly caused by
careless use of the catheter, or through forced bougieing, generally dis-
appears after a few days. It is most troublesome during the act of swal-
lowing, and respiration is somewhat impeded only when the swelling is of
considerable extent. Often a continuous, troublesome tickling and itching in
the pharynx will arise, which cause the patient to clear the throat repeatedly,
whereby the emphysema frequently increases in extent, because by the forced
acts of expiration air is driven below the mucous membrane at the injured
point. It is therefore important to recommend patients, after the occurrence
of emphysema, to suppress as far as possible the clearing of the throat and
the act of swallowing. If the sweUing assumes such an extent that it pro-
duces difficulty in breathing, an exit for the air may be made by tearing the
pharyngeal mucous membrane with the nail of the forefinger, or, according
to Guye, by cutting the soft palate with scissors. In cases of emphysema
affecting the cheeks and the neck, friction of the parts has been recom-
mended— ^but is not, in my opinion, a good method of treatment, for it drives
the air towards the pharynx, rather increasing the disorder.*

If, therefore, on compression of the balloon great resistance is felt, it is
advisable to draw back the instrument a Uttle, whereby, as a rule, the orifice
of the catheter is rendered free and the air can penetrate unchecked into the
canal. In order to avoid such obstacles, which are caused by the catheter being
improperly fixed, it is advisable before each compression of the balloon to
slightly approximate the catheter to the balloon with the thiunb and fore-
finger of the left hand, to counteract the backward movement of the instru-
ment consequent to compression. To avoid the blow of the balloon upon the
catheter, it may be connected with the catheter by means of a short piece of
india-rubber tubing.

The most powerful action of the baJloon is obtained when, as in Fig. 77,
it is fixed by the thumb and palm of the hand, and compressed from the side
by the four fingers. On the other hand, the pressmre is considerably less
when the fingers are apphed round the neck and the balloon is compressed
by the thumb laid at its base. Hartmann obtained a pressure of 888 mm.
Hg. by the former method and only 260 mm, Hg. by the latter.

The air being heard to enter the middle ear freely, the subsequent
compressions, 6-6 in number, should be rapidly and powerfully
carried out. On this chiefly depends the therapeutic value of the
air-douche. After each compression the balloon requires to be
removed from the catheter so that it may again be filled with air.

To avoid the removal, balloons with valves have been constructed, but
experience shows that they soon get out of order. Perforated balloons have

* The extension of the emphysema to the cavum tympani and membrana tjmpani
(Schwartze) and to the mastoid process is one of the most rare occurrenoes.

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PBOPEIiLINQ AIB INTO THE MIDDIiE EAR BY THE CATHETEB. 103

also proved unsuitable, because the orifice by frequent use very soon becomes
dilated. Bellows and treadle-balloons which were formerly, and even again
recently, recommended, have gained no place in practice, as even with large
bellows only an insufficient pressure is produced.

Although this mode of inflation suffices in the majority of cases requiring
the air-douche, it unfrequently occurs, however, that the resistance in the
Eustachian tube and in the tympanic cavity cannot be overcome by it, or, if
the air enters into the middle ear, the current is so weak that it is necessary
to use a force-pump.

My force-pump (Fig. 78) consists of a globular metal receptacle, 14 cm. in
diameter (e), in which the air is condensed by a piston, working in a tube (d).

Fig. 78.— Fobcb-pump.

The difference of this pump from its predecessors is, that its manipulation
does not require the least exertion, that the compression of air in the pump
to the necessary degree can be accomplished in a very short time and with
only one hand, and that the strength of the escaping current can be exactly
regulated. A double-acting valve renders it possible, by a rapid upward and
downward motion of the piston, to increase the pressure to | atmosphere in
the space of fifteen seconds. Considerable advantage is gained in this pump
by the lever- valve (6) fitted on the escape-pipe. By it the strength of the
current of air can be fixed according to the size of the angle formed by the
lever with the vertical ; also, if a powerful current of air, of short duration,
is to be appUed, it can be instantaneously interrupted by a rapid backward
and forward movement of the lever. The india-rubber tube (c), connected
with the escape-pipe, is furnished with a conical nozzle (a), which is fitted
into the outer extremity of the catheter.

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104 PBOPELLINa AIB INTO THE MIDDLE EAR BY THE CATHETER.

To determine the pressure of air in the pump, an open or closed quicksilver
manometer, or a spring one, may be connected with the escape-pipe behind
the valve. In force-pumps not provided vdth a manometer, the pressure
may be measured by testing with a manometer the nimiber of motions of the
piston required to produce ^, g, ^, and 1 atmospheric pressure.

Before the compressed air is allowed to pass through the catheter into the
tympanic cavity, it is necessary to ascertain by the use of the balloon that the
catheter is correctly placed in the Eustachian tube. If this precaution is dis-
regarded, serious accidents may happen, as the mucous membrane of the
tube or of the naso-pharynx may be injured by the rapid entrance of a current
of air, giving rise to extensive emphysema of these parts. For besides the
pain, choking sensations in the throat, and dyspnoea, suffocative attacks may
occur if the emphysema spreads downwards to the entrance of the larynx.*

The double balloon, which was reconmiended by Lucae and Schwartz, may
be used in those cases in which only a small pressure is required, but its
therapeutic value will be found to be much less than the simple air-bag. I
must, however, modify my former statements somewhat in this respect, that
with the new larger double balloons much better results may be obtained
than with the small ones formerly used. The strength of the current of air
with the double balloon can be increased by compressing the tube as well as
the balloon when filling the latter, and further by forcibly compressing the
latter as the air is leaving it.

The assimiption that a constant current of air can be kept up with the
double balloon is not quite correct, since at each compression of the balloon
a variation in pressure arises. Lucae (A,f, 0., vol. xx.) recommends Munck*s
water-bellows for the purpose of creating either a constant or interrupted
current. This instrument may easily be made use of in clinical institutions,
but the construction is too expensive and complicated for private practice.

Blowing air into the catheter with the mouth, still practised by many
specialists, is only to be employed in exceptional cases ; for, apart from the
fact that the expiration-force is mostly too weak to be of therapeutic value,
the majority of patients are reluctant to be operated on in this manner.

Results of Auscultation in Normal and Pathological Conditions of the

Middle Ear,

The signification of auscultation for the diagnosis of middle ear
affections is very often over-estimated, and, on the other
side, too often imder- estimated. Although auscultation very
often gives a negative or indefinite result, in certain cases it
gives conclusive diagnostic evidence. It can only be relied upon
in connection with other symptoms. If air is propelled into the
normal middle ear by the catheter, the listener will hear a large,

* In two cases of Tumbull's of London, where sudden death occurred daring the
application of the force-pump, the fatal cause remained unexplained. It is quite
probable that the entrance of the larynx was dosed up by a considerable submucous
emphysema, and that death from suffocation ensued.

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BESULTS OP AUSCULTATION OF THE NOBMAL EAB. 105

dry, protracted, blowing sound, similar to that which is produced
if the tongue is brought near the hard palate and the act of expira-
tion is performed quickly while the lips are almost closed. .But
the flapping sound, which is noticed during the Valsalvan experiment,
is rarely perceived. This blowing sound (Deleau's bruit de pluie),
which is caused by friction of the air on the walls of the Eustachian
tube and of the tympanic cavity, and receives its pecuhar character
mainly from the friction of the air on the inner surface of the mem-
brana tympani, has various degrees of strength and distinctness,
which are dependent on the varying width of the Eustachian canal
in different individuals.

The calibre of the catheter, the size of the orifice at its point, and
its position with regard to the walls of the Eustachian tube, exercise
a considerable influence on the pitch and the intensity of the aus-
cultation-sounds, in the normal as well as in the diseased ear.

By using slender catheters, a higher and shriller sound will
generally be heard than by propelling air through a catheter with
a wider limaen. A change of the auscultation-sound may cJso occur
during catheterization, if the orifice in the beak of the catheter is
relatively narrowed by lying against the wall of the tube through
a change in the position of the instrument.

It has already been insisted that the Eustachian tube is
^ddened by the act of swallowing so that it gapes. Thus the air
propelled through the catheter during the act of swallowing is heard
to enter the tympanum with a much louder noise. It is con-
sequently better, in order to increase the therapeutic effect, to have
the patient swallow repeatedly daring the catheterization.

This presence of a distinct sound of air entering during the act of swal-
lowing does not justify the conclusion that the catheter is properly inserted
in the Eustachian tube, since even when the point of the catheter is situated
either before or behind the orifice of the tube, air may enter the cavum
tympani through the tube, which, as before mentioned, opens during
swallowing.

The ciurent of air, which in pathological cases occasionally reaches no
farther than the isthmus tubse, produces a soimd which bears a remote
resemblance to that caused by air entering the cavimi tympani, and con-
sequently may be easily mistaken for the latter by practitioners of no great
experience. The diflerence, however, is that the former is much weaker and
softer, and seems far more distant than the latter, which is heard as if it
arose immediately under the ear of the examiner.

In some cases, mostly pathological, in which no sound is heard in spite
of the entrance of the air into the cavum tympani, I use the ear manometer
(Fig. 61) designed by me, which is inserted hermetically into the external
meatus, to ascertain whether air has entered the cavity. Every time the

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106 RESULTS OP AUSCULTATION IN PATHOLOGICAL CASES.

inflating-bag is compressed and air enters into the tympanic cavity, the drop
of fluid with which it is supplied will rise, owing to the bulging forward of
the membrana tympani.

The normal auscultation-sound caused by the use of the air-douche is
subject to many changes in diseased states of the middle ear. To estimate
the value of these abnormal sounds, we must bear in mind that we have to
deal generally with a combination of sounds, caused partly by free exudation
in the middle ear, partly by swelling of the lining membrane of the middle
ear and strictmre of the Eustachian tube, and partly by morbid changes in
the membrana tympani. That the strength of the air-current influences the
quality of the soimds need hardly be mentioned.

There is usually a considerable difference between the auscultation-soimds
produced in cases of perforate membrana tympani and those in cases in which
the membrane is intact. When the membrane is not perforated, the sounds
heard on auscultation vary directly with the amount of swelling and secretion
in the middle ear. In cases of accimiulation of secretion in the middle ear,
rattling noises, differing in quality, will frequently be heard whilst the air-
douche is being used. These rattling noises originate most frequently
in the Eustachian tube, especially when it contains rather fluid secretion.
They are less frequently due to the passage of the air through accumu-
lations of secretion in the tympanic cavity. But if a considerable quantity
of fluid secretion has collected, such sounds will often arise in rapid succes-
sion, may even be heard without the auscultation-tube, and frequently
continue for some time after the inflation ; while, with a scantier secretion,
the presence of which can be proved by inspection of the membrana tympani,
frequently no such sounds will be heard.

In the case of a secretion of fluid consistence there is generally heard a
rMe of a flne bubbling character ; on the other hand, in the case of thick,
tenacious secretions, the sound has a larger, uniform, and more interrupted
bubbling character, the interruption sometimes having the character of a
rough friction-soimd, caused by a simultaneous swelling of the mucous
membrane of the tube and an alteration in the tension of the membrana
tympani. A distinct rAle is often heard only at the commencement of the
inflation, soon followed by a rough or freer inflation-sound if the secretion
lodged in the tube has been removed by the first inflation of air, or if during
the introduction of the catheter mucous secretion from the naso-pharynx
has stuck to its point and got into the tube with the beak of the instrument.
This occurs frequently, and may give rise to mistakes, because the rattling
sounds so caused might be looked on as a consequence of hypersecretion of
the mucous membrane of the tube.

The rattling sounds produced by mucus in BosenmUller's cavity or near
the orifice of the tube, when the catheter is incorrectly placed, must be dis-
tinguished from those already described. As has long been known, it differs
from the sounds produced in the middle ear in that it resembles the bursting
of large bubbles, and is heard as if distant from the ear. Grating sounds
are also observed in the pharynx during the application of the air-douche,
caused partly by vibrations of the membranous wall of the tube, partly by the
vibration of the soft palate when the air is returning.

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RESULTS OF AUSCULTATION OP THE MIDDLE EAR. 107

That the friction of the air on the inner surface of the membrana tympani
gives the particular character to the auscultation sound is proved in cases of
anomalous tension of the membrana tympani. Especially when the mem-
brana tympani is relaxed from cicatrices, as a consequence of atrophy of
the membrane, or when there is cicatricial adhesion between the membrane
and the inner wall of the cavxmi tympani, even when the passage through
the Eustachian tube is normal, a sharp, high, vibrating sound is produced,
which appears to be so near the ear of the auscultator that it may easily
be mistaken for the auscultation sound in perforation of the membrana
tympani.

When auscultation is doubtful in these cases it can be decided by use of the
ear manometer. Where there is no perforation the fluid only rises in the
tube, but where the membrane is perforated the fluid wiU be expelled from
the tube.

In inflammations of the middle ear without swelling or secretion the aus-
cultation-soimds vary. If the tube and the membrane are not affected, as is
the case in the circumscribed inflammations of the middle ear, which cause
stiffiiess of the ossicular articulations, but more commonly anchylosis of the
stapes, the normal blowing-sound wiU always be heard. In cases of more
general thickening of the mucous membrane of the middle ear, however,
where the membrana tympani is also drawn inwards, there will be heard
only a weak, dry, thin soimd, or sometimes a high, shrill or whistling one.

The character of the auscultation -sound in a case of perforated membrane
depends on the presence and quantity of secretion in the middle ear, on the
degree of stricture of the Eustachian tube, and also on the size of the perfora-
tion. Either a hissing sound combined with a ratthng, perceptible even
without the auscultation-tube, or, where there is scanty secretion and a
strictured tube, a high-pitched whistling or hissing soimd without any
rattling is heard. If the tube is dilated, which occurs after suppurative
inflammation of the middle ear, a blowing, puffing soimd will be perceived,
even if the perforation in the membrane is small. As the air which comes
through a perforation passes into our ears through the auscultation-tube,
these sounds will be heard as intensely as if they had their origin in our own
ear. In cases where the margins of the perforation lie closely together,
where also inspissated purulent masses, growths of mucous membrane in the
tympanic cavity, or adhesions closing the tympanic orifice of the Eustachian
tube cause obstruction to the air entering the cavum tympani no perforation
sound may be heard.

Concerning the auscultation of the mastoid process, Laennec* has already
proved that the air entering into the middle ear produces a soimd in the
mastoid process, plainly perceptible by auscultation, and that also rattling
sounds in the middle ear are beard by auscultation at the base of the mastoid
process, and the locality of their origin can be distinguished. According
to Dr. Michael f if a blowing auscultation-sound is heard in the mastoid
process of the living, it can be positively asserted that the mastoid cells are
filled with air and are therefore free from any pathological products. When

• Sur VAuscuUcUion midicUe, 1835, p. 57.
t Arch, far OhrenhtUhwide, voL xi., p. 46.

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108 INJECTION OP FLUID INTO THE MIDDLE EAP.

the permeability of the Eustachian tube is much impaired, as well as when
there is perforation of the membrana tympani, no sound whatever wiU be
perceived in the mastoid process. If these two conditions can be excluded
and the sound be absent, a diseased state of the mastoid cells may be inferred
{e.g,f exudation, cheesy masses, growths of mucous membrane, sclerosis).

7. Methods of Injection of Fluid and of the Introdiiction of Vapours
into the Middle Ear through the Catheter,

Injections of fluid through the catheter are employed in the dif-
ferent forms of disease of the middle ear. Their purpose is : (1) in
swelling and hyper-secretion, by the immediate action of the medi-
cated fluid upon the diseased mucous membrane, to lessen the
secretion, and to cause a decrease in the swelling of the lining
membrane; (2) in that form of disease in which, in consequence
of condensation of the mucous membrane, a Arm union of the
ossicula with each other and with the walls of the tympanic
cavity exists, to effect an irritation and loosening of the rigid mucous
membrane, and thereby a greater mobility of the ossicula, by the
injection of slightly irritating fluids ; (3) in accumulation of inspis-
sated secretions, to bring about their removal by liquefying them.

The quantity of the fluid penetrating into the tympanic cavity is the greater
the farther the point of the catheter is pushed towards the isthmus tubee, and
the more exactly the orifice of the instrument corresponds with the direction
of the Eustachian tube. In no case is it possible to judge accurately what
quantity of the injected fluid has reached the cavum tympani, since on
account of the funnel shape of the tube and the bend in the canal at the
isthmus a partial escape of the fluid cannot be prevented.

The details of the method of injection of small quantities of fluid into the
middle ear, as at present in use for purposes of treatment, are the following :
After the catheter has been introduced into the Eustachian tube, air is injected
two or three times into the tympanic cavity by means of the inflating-bag to
remove secretion, which might be deposited in the tube, and would obstruct
the entrance of the fluid.

Next 6-8 drops of the slightly warmed medicated fluid are put into the
catheter by means of Pravaz's syringe, and the fluid is blown into the middle
ear by the balloon. Care must be taken that the head of the patient remains
in the erect position, because if the head is inclined backwards, the fluid in
the catheter will escape into the pharynx before the propulsion into the
middle ear has taken place.

When the membrana tympani is imperforate a sharp sound will be heard
as it enters the ear accompanied by a fine crepitation which may often be
heard for some time after the injection. The inspection of the membrana
tympani will show either an unaltered state of the membrane, or a more or
less marked injection of the vessels of the handle of the malleus, and great

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INJECTION OF FLUID INTO THE MIDDLE EAB. 109

congestion of the neighbouring portions of the superior and posterior walls of
the meatus ; this occurs not only with the application of irritating injections,
but also sometimes with the employment of quite indifferent fluids. Small
quantities of fluid are seldom seen after injection to shine through the mem-
brana tympani; large quantities of fluid will, however, be seen to shine
through, especially when the membrane is transparent, and the fluid is
coloured.

The subjective symptoms which occur after inflation consist
mostly of a sensation of fulness and warmth, sometimes of burning,
more rarely of acute pain in the ear and a passing sensation of
taste (Moos). I have seldom observed great reaction with subse-
quent inflammation in the middle ear, and never an inflammation with
suppuration in the tympanic cavity, and perforation of the mem-
brana tympani. Frequently the escape of a portion of the fluid into
the pharynx causes an unpleasant itching, hawking, and cough,
which can be most quickly removed by gargling with cold water.
Acute pain in the ear after the injection is removed, either by
rubbing the region of the external ear, by simply breathing into the
ear, or by pouring lukewarm water into the external meatus.

For the injection of larger quantities of fluid into the middle ear a thicker
catheter with a longer beak is used, and is pushed as far as possible into the
Eustachian tube. The injection is effected by a vulcanite syringe, made to
contain 80-100 grammes, the nozzle of which can be fitted hermetically into
the outer extremity of the catheter. The greater the resistance in the middle
ear, the more dif&cult is the injection of fluid into the tympanic cavity ;
indeed, even with a permeable tube and a perforated membrane, and with
the point of the catheter well pushed in, only a portion of the injected fluid
will escape at the external meatus, the greater portion making its way into
the pharynx or the nose.

In cases in which the cavum tympani is either partially or wholly filled
with inspissated secretion or by proliferation of the mucous membrane, so
that the injected fluid cannot force its way into the cavum tympani, but
flows back into the pharynx instead, it is advisable to use the elastic tympanic
tube recommended by Weber- Liel. I have found this instrument, which
was originally intended for sucking exudation out of the cavum tympani and
for injection of medicated fluids into the tympanimi, invaluable in the
treatment of certain diseases of the middle ear, external meatus, and mastoid
process, and almost indispensable in the practice of disease of the ear.

The tympanic catheter (Fig. 79) consists of a small flexible tube, funnel-
shaped at its outer extremity, 17 cm. long, and l'H mm. thick, with a 6mall
aperture at its point (or on its side) for the exit of air or fluid.

The introduction of this tube into the tympanic cavity is effected in the
following manner: a moderately thick vulcanite catheter, 12 cm. long,
through which the small catheter can easily be pushed, is first introduced
into the Eustachian tube. The point of the small catheter wiU be in the

Digitized by VjOOQIC

110 INJECTION OF FLUID INTO THE MIDDLE EAK.

t^^mpanum, when it has been pushed 2 J -8 cm. beyond the point of the
catheter, as indicated by a mark previously made on its outer extremity.
Inasmuch as the catheter is held in position by the tympanic tube,
Delstanche*s clamp is unnecessary for fixation.

According as a smaller or larger quantity of fluid is to be injected,
either Pravaz*s graduated syringe or a larger one is used, and its nozzle
must fit into the funnel-like widened extremity of the tympanic
catheter. As the friction of the fluid in the latter is ver^' great,
a considerable amount of pressure has to be employed during
the injection; this pressure must be increased only gradually,
because if outflow into the external meatus is prevented, violent
pain and giddiness may arise from the suddenly increased pres-
sure of the injected fluid upon the walls of the tympanum.

When the fluid injected either by the catheter alone or by aid of
the tympanic tube is entering the tympanic cavity, a dull rushing
sound will be heard similar to that which is perceived when one
listens over an india-rubber tube through which fluid is flowing.
When a considerable quantity of fluid is injected, although the
tympanic catheter has been used, a large portion will flow into the
naso-pharynx.

The injection of large quantities of fluid into the middle ear by
the catheter as well as by the tympanic tube I consider applicable
only in those affections of the ear where a perforation of the
membrana tympani exists, and where, therefore, the fluid injected
into the tympanic cavity may escape again through the external
meatus. Referring to the special division for the indications for
this method, we will here only mention that injections of warm
water are speciaUy serviceable when there is violent inflamma-
tion in the middle ear in consequence of inspissated secretion,
and where liquefaction and removal of the inspissated exuda-
tion have to be effected. They are also successfully employed in
those cases where, in the course of chronic suppuration of the
middle ear, even without retention of secretion, an acute inflam-
mation is intercurrent, accompanied by violent pain and with
, or without an osseous affection.

We must, however, disapprove of such injections in those afifec-

YiQ^yg^ tions of the middle ear in which the membrana tympani is not

Klastio perforated. Deleau,* and Bonnafont,t speaking from considerable
Ttmpanio experience, have already pointed out the injurious consequences in
the middle ear which follow the injection of large quantities of
fluid when the membrana tympani is intact, for, after the introduction of
a large quantity of fluid into the middle ear, there is not unfrequenUy a
most violent reaction, accompanied by the development of a very painful
suppurative inflammation of the middle ear, with perforation of the mem-
brana tympani, which may lead to fatal complications.

♦ TraiU du CcUhiUrisme de la Trompe d'Euatache^ p. 63.

t TrmU tkSorique et pratique des Maladies d' Oreille, 1860, p. 77.

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INJECTION OP VAPOUBS INTO THE MIDDLE EAB. Ill

The method of mtroducmg hougies into the Eustachian tube will be
described in the treatment of stricture of the tube.

The introduction of medicated substances in the form of vapour in the
treatment of the diseases of the middle ear was formerly practised more
frequently than now. The volatilizers proposed by Itard, Kramer, Lincke,
Wolf, Bau, and others, have almost all gone out of use, and at present, in
the rare cases in which vapours are introduced into the middle ear, more
simple instruments are employed, of which the one designed by v. Troltsch
is the most practical, on account of its compendious form and easy production.
This apparatus consists of a glass bottle with a wide neck, closed by a stopper
of vulcanized india-rubber pierced with three holes, and fixed on a stand.
Into the middle orifice is inserted a thermometer to ascertain the temperature
of the vapours, in the lateral orifices two curved glass tubes ; the one serves
for the conduction of the compressed air, and the other with a rubber tube
attached is for the introduction of the vapour into the tympanic cavity. The
steam is produced by means of a water or sand bath heated with a spirit-
lamp.

For the appHcation of sal-ammoniac vapour * Kerr's Inhaler,' as modified
by me, is to be recommended. This apparatus (Fig. 80) consists of a glass
bottle holding ^ litre filled about one-third full of water, with a broad india-
rubber stopper having a large and a small opening in it. The straight leg of
a Y-shaped glass tube is passed through the larger opening in the neck of
bottle, and is immersed into the water contained in the bottle (^, Fig. 80),
a thin rectangular tube being passed through the smaller orifice so as not to
reach the surface of the water. If a longish piece of asbestos, which has been
dipped into hydrochloric acid, be now suspended in the arm, n, of the Y-shaped
tube by means of a thin wire, and a small sponge saturated in ammonia be
similarly placed in the other arm, a, when the air contained in the glass vessel
b sucked out through the rectangularly bent tube, m, the vapours of hydro-
chloric acid and ammonia will imite to form sal-ammoniac in the lower
section of the tube, which passing through the water may be inhaled in a
purified form.

The apparatus so frequently used for the inhalation of chloride of am-
moniiun vapours in the treatment of laryngeal and bronchial catarrh is
employed by many English aural surgeons (Dalby, Urban Pritchard), more
especiaUy in cases of dry catarrh of the middle ear, in such a manner that the
vapour taken into the mouth is further forced into the middle ear by means
of Valsalva's method. I cannot, however, recommend this method, for it
enables only a small portion of the vapour to be introduced into the middle
ear, and furthermore, one possesses all the disadvantages of Valsalva's
method {vide following section).

The above-mentioned apparatus is modified in the following manner for
the purpose of introducing sal-ammoniac vapours into the middle ear by
means of a catheter. The two ends of a bifurcated glass tube, g, the stem of
which is attached to a double balloon, are connected by means of short pieces
of india-rubber tubing with two bent glass tubes, r, r, each of which carries
a perforated rubber stopper at its other extremity, these stoppers being
accurately fitted into the glass tubes a, n. On pressing the double balloon.

Digitized by VjOOQIC

112

INJECTION OF VAPOURS INTO THE MIDDLE EAB.

vapours of hydrochloric acid and ammonia are forced into the lower section
of the Y-shaped tube, where they unite to form sal-ammoniac vapour, which
being purified in its passage through the water may now be conducted through
a rubber tube, «, and catheter, c, into the cavum tympani.

In all the apparatus for the injection of vapours, the impregnated air leaves
the nozzle of the catheter with far less energy than is the case with the
ordinary air-douche. The pressure being thus so slight, the vapours can only
reach the tympanic cavity provided the tube be permeable. In cases in
which the tube is much swollen both the simple and double balloons will be

Fig. 80. —Apparatus for Chloride op Ammonium Vapour.

insufficient as a compression apparatus, and recom-se must be had to the
force-pimap. Perforation of the membrana tympani greatly facilitates the
entrance 6f vapours into the middle ear.

The temperature of the vapour will vary with the natm-e of the medica-
ments employed, some of which volatilize at a low, others at a high, tempera-
ture. The duration of the injection depends likewise on the nature of the
drugs employed and upon the amount of irritation which is developed during
the action of the vapour in the ear or pharynx. GeneraUy the time of the
application varies from 3-10 minutes.

When applying rapidly evaporating fluids such as sulphuric ether, acetic

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INJECTION OP VAPOUBS INTO THE MIDDLE EAB. 113

eiher, ethylic iodide, chloroform, turpentine, etc., a volatilization apparatus is
not required. In such cases the simple rubber balloon as used for the air-
douche is sufficient, the vapours being collected by placing the point of the
eompressed balloon into the small bottle containing the medicated fluid (not
into the fluid), and then gradually relaxing the pressure.

The introduction of vapours into the middle ear is accompanied by a feeling
of warmth and fulness in the ear. Great burning or a stabbing pain with,
at the same time, injection of the vessels along the handle of the malleus,
occurs most frequently after the action of ammonia vapours. The escape of
vapours into the naso-pharynx often causes great itching, hawking, coughing,
congestion, and swelling bf mucous membrane with increased secretion.

Far smaller quantities of the vapours passed through the catheter reach
the middle ear than was formerly supposed. This is equally true for simple
steam, or that impregnated with drugs, and for ammonia vapours which are
precipitated at the isthmus tubse, more especially in cases of injection of the
tube, although larger quantities enter the tympanic cavity when the tube is
readily passable. On the other hand, the finely divided vapours of the
various forms of ether, chloroform, turpentine, and likewise carbonic acid as
recommended by Beute and Bau, and hydrogen as recommended by Lowen-
berg, may be easily propelled into the middle ear, even when there is con-
siderable obstruction in the Eustachian tube.

c. The Author*8 Method of making the Eustachian Tube Permeable.
{Politzer*8 Method,)

The method of making the Eustachian tube permeable, which
I published in 1863,* is based upon the fact that the air in the
naso-pharynx, when closed on all sides, becomes condensed during
the act of swallowing, and is thereby forced through the Eustachian
tube into the middle ear. The essential novelty of this method,,
by which it is distinguished from catheterization of the Eustachian
tube, lies in the fact that the nozzle of the instrument to be used
for condensation of air is introduced only into the anterior portion
of the nasal cavity, and thereby introduction of the catheter into the
Eustachian tube, which is sometimes impracticable and often dis-
agreeable, is avoided. The closure of the naso-pharynx in this
method is effected, behind by the soft palate being closely applied
to the posterior pharyngeal wall, and in front by compression of the
alsd of the nose. At the same time the resistance in the tube is
lessened by the act of swallowing, by which the influx of the con-
densed air into the tympanic cavity is materially facilitated.!

• Wiener mid. Woehennehrijl, 1863, No. 6.

f This method wm suggested by a number of ezperimentt made in reference to th<»
fbetoations in the pressure of air in the tympanic cavity. I quote here the second
eiperiment ( VF. med, FT., 1863, v. 6), which I demonstrated to Professor v. Troltsch

Digitized by VjOOQIC

114 POIilTZEB'S METHOD.

The most serviceable mstrument for my method is a pyriform ballooB
(Fig. 81), about the size of the doubled fist (10-12 oz.), which is furnished
with a slightly curved tubular nozzle. To avoid bleeding, which is frequently
produced by the immediate impact of the stiff nozzle upon the pituitary
membrane, the connection between the balloon and the nozzle is effected by
the insertion of a short elastic india-rubber tube. For some years past I
have used in my practice the rubber balloon (p. 101) which is usually only
employed for catheterization, its nozzle being provided with a somewhat
rigid india-rubber tube 3^ cm. long (Lowenberg).

The details of the method are the following : The patient, being
seated in a chair, takes a little water into his mouth — to facilitate

Fig. 81.— Politzke's Method.

swallowing — which he is required to swallow when told.* The
surgeon, standing on the patient's right, or in front, introduces the
nozzle of the Politzer-bag one cm. into the nasal orifice of the cor-

in 1861. If I introduce the extremity of the escape-pipe of a force-pump into the
noae, half an inch deep, and compress the alse round it, and then perform an act of
uwallowing while the compressed air rushes into the nasal cavity, I feel the air at the
same moment entering with force into both tympanic cavities, while the drop of fluid
in a manometer, inserted into the external meatus, moves outwards.

* The use of water is by no means absolutely necessary in all cases during the
application of my method, which I often perform during a simple act of swallowing,
the effect of an energetic act of deglutition being the same as that of drinking water.
Sometimes, however, the simple act of swallowing is less powerful, and not only is
deglutition in such cases materially facilitated by drinking water, but the lumen of
the Eustachian tube is also more widened by the powerful contraction of the naso-
pharyngeal muscles, and the effect of the injected air is increased. Miot gives the
patient a small piece of sugar instead of water, by which salivation is prodnoedf
facilitating the act of swallowing.

Digitized by VjOOQIC

politzer's method. 115

responding side at its posterior angle, and then compresses with the
left thumb and forefinger the alsB of the nose closely round the
instrument. The patient is next told to perform an act of swal-
lowing, and at the same moment the surgeon expels the air from
the iniiating-bag with his right hand. By the condensation of air,
produced in the naso-pharynx in this n^anner, the air is forced into
both middle ears, the closure effected by the soft palate is forced
open, and its vibrations give rise to a duU gurgling noise which
frequently, if not always, may be taken as an indication that the air
has entered into the middle ear.

The majority of patients experience at the same time the subjective sensa-
tion of a stream of air entering both tympanic cavities, but the sensation may
be entirely absent, even in, persons who have normal sensibility of the mucous
membrane of the middle ear, as well as those in which the sensibility is
impaired. Children who are suffering from catarrh of the tube will be seen
to put the hands up to their ears at the moment when air enters the cavmn
tympani (Pagenstecher) . The bulging of the membraoa tympani will generally
be seen to be more than by the Yalsalvan method or by catheteriza-
tion. The effect is most pronounced upon the membrana tympani when
there is either total or partial retraction, as the retracted part will be bulged
out, sometimes even in the form of a bulla.

The results of auscultation diunjig the author's method may be sunmiarized
as follows : That even with an intact membrana tympani, in spite of the
gurgling noises in the pharynx, the sounds which have been produced in the
middle ear can be plainly distinguished, as by continued practice we are
enabled to disregard the more distant pharyngeal noises, and to concentrate
our attention upon those nearer ones.

During the application of my method we will therefore often hear the
hulging-out noise of the membrana tympani (Moos) and the abnormal aus-
eultation-sounds which were mentioned during the description of the operation
of catheterization. While, however, during catheterization the noise appears
modified by the friction of the air in the catheter and by its escape from the
point of the instrument, the auscultation-sound during the application of my
method, where these disturbances are absent, is comparatively often more
-dearly beard. When there is perforation of the membrana tympani the
escape of air through the external meatus can even be heard without an
otoscope.

Where the iiispection gives a negative result after the entrance of air into
the middle ear it may be proved by using the ear manometer in the external
meatus, provided with coloured fluid as previously described (vide p. 64).

The air, condensed in the naso-pharynx by my method, will as
A rule enter into both tympanic cavities, more powerfully, however,
on the side where the resistance in the tube and in the tympanic
cavity is feebler. Therefore to concentrate the effect of the current
of air upon the diseased ear, when only one is affected, and to hinder

Digitized by VjOOQIC

116 P0LITZEB*8 METHOD.

the entrance of ait into the normal one as much as possible, it is
necessary to create an artificial resistance in the latter by her-
metically closing its meatus with the finger. In oases in which
both ears are affected, the same measure may be adopted; as for
instance when, owing either to perforation of the membrane or to
diminished resistance in the Eustachian tube, the entrance of air
into one ear takes place more readily than into the other. In such
cases, where we wish to inflate the latter more powerfully, the
meatus of the former must be hermetically closed with the finger.
Indeed where both ears are affected, and the current of air pene-
trates equally strongly into both cavities, the mechanical and there-
fore also the therapeutic effect of inflation can be increased by
closing the meatuses alternately, to allow the full power of the air-
current to act separately upon each tympanic cavity.*

The strength of the air-current to be employed depends generally
on the amount of resistance in the middle ear, on the presence of
inflammatory phenomena, and also sometimes on the pathological
changes in the membrana tympani. In the case of slight obstacles,,
which may be assumed when the hearing-power has not been much
diminished, and also in acute inflammations of the middle ear, where
the reactive phenomena, especially the pain, have not completely
disappeared, currents of slight pressure are advisable. For thisi
purpose the introduction of air may be effected either by the mouth,,
by blowing through a short india-rubber tube, or by the balloon, in
the application of which the pressure by using two, three, four, or
five fingers can be regulated so that the air will enter the cavum
tympani either with a mild or strong pressure as wished. In cases-
of great resistance, however, the permeability of the Eustachian
tube must be effected by powerful and rapid compressions of the
balloon or with the double balloon. The air-pressure needed for
my method varies from 0, 1-0, 4 atmospheres and above.

The effect of inflating with air after the author's method depends on the
nature of the pathological changes which impair the function of hearing. In
those affections of the middle ear where, in consequence of swelling and
accumulation of secretion, and of the abnormal tension of the membrana
tympani and of the ossicula combined with it, a high degree of deafness often
exists, a striking improvement in the hearing wiU generaUy follow the ap-
plication of my method ; where, however, in the course of inflammatory pro-
cesses in the middle ear a development of newly-formed connective tissue,
and thereby abnormal anchylosis of the ossicula with each other and with
the waUs of the tympanic cavity have taken place, or in deafness from

* Lowenberg recommends for this purpose a balloon fitted with a side tube for the
meatus.

Digitized by VjOOQIC

politzbr's method. 117

nervons ongin, either no improvement in the hearing or only a slight one
is effected by this method. The feeling of improvement in the hearing wiU
often correspond with a demonstrable increase in the hearing-distance ; how-
ever, cases are not unfrequent where the patients complain after the applica-
tion of my method of a feeling of nmnbness in the ear, while by testing, a
considerable increase in the hearing-distance is ascertained.

The sensation of pressure in the region of the stomach which sometimes
occurs immediately after the employment of my method is chiefly observed
as the result of considerable pressure applied by means of the force-pump,
more seldom seen after the use of the balloon. This sensation is caused by
the abrupt entrance of air into the inferior portion of the oesophagus, but it
may very quickly be removed by making the patient take several deep breaths
in succession. Other accidents which rarely occur by the use of my method
are dizziness, sense of fulness in the head, and pain in the forehead.
Bupture of the membrana tympani, which also occurs by Valsalva's method
and catheterization, occurs very seldom by my method when carried out by
swallowing or during phonation. The rupture occurs mostly in those mem-
brana tympani which are either atrophic, thinned by cicatrization, or contain
deposits of chalk.*^ Such ruptures, according to the observations of Pagen-
stecher, Schwartze, von Horck, Oradenigo, and myself (Wiener, Med,
Fresse^ 1868), are followed by no bad results, but in fact by a noticeable
improvement in hearing which generally remains. If one wishes to guard
against a rupture of the membrane during the use of the air-douche it is best
to close the external meatus by means of the finger.

My method has in the coiurse of years been modified, partly by myself and
partly by others, and the original indications have been increased. It is
worthy of special notice that the effect of this method is not confined to the
middle ear alone, but that secretion in the naso-pharynx, and even in
the cavities adjoining the nose, is removed by the air-current (Hartmann).
The modifications refer partly to an alteration in the form of the instrument,
partly to the closure of the soft palate.

The modifications of the form of the instrument have for the most part
proved impracticable. Olive-shaped nozzles, even when tightly fitted into
the nostrils, cannot prevent the reflex of air from the nose. Long tubular
nozzles (Grazzi) diminish the strength of the pressure. Still less useful was
the application to both nasal orifices of a plate pierced with two holes, as pro-
posed by AUen. The substitution for the hard nozzle of a short india-rubber
tube (Lowenberg), however, appears to me very serviceable, because the
painful sensation which is produced by the compression of the nasal wings
round the hard nozzle as well as the occurrence of bleeding from the nose
are avoided. The employment of a short elastic nozzle is also recommended
on the ground of cleanliness, as each patient can be provided with a separate
tube, thus excluding completely the possibility of infection. The manipula-
tion of this nozzle, however, requires a certain amount of practice, inasmuch
as complete compression of the india-rubber tube must be avoided when

* The normal membrana tympani can be mptnred by a prestore of 8-4 atmo-
spheres (Schmiedekam). In practice, however, we i»eldom use a pressure of more
than i atmosphere.

Digitized by VjOOQIC

118 politzeb's method.

pressing the alse of the nostrils together, and on the other hand, the escape
of air past the tube and through the nasal orifices must be prevented.

Regarding the various proposed modifications of the method of closing the
soft palate, it was first proved by Schwartze* that, especially in children, air
can penetrate to the middle ear by applying the author's method even with-
out the act of swallowing. The reason for this is to be found partly in the
narrowness of the naso-pharynx and in the shortness of the Eustachian tube
in the child, partly in the fact that the soft palate is reflexly lifted up by the
action of the current of air on its upper surface, is applied to the posterior
pharyngeal wall, and doses the naso-pharynx downwards. Ldwenberg f
found that the act of swallowing during the application of my method may
be replaced by a simple lifting of the soft palate. I observed myself in
patients who began to speak at the moment of compression of the balloon, that
the compressed air in the naso-pharynx was forced into the cavum tympani.
Based upon the fact, which was proved experimentally by Czermak and
Brilcke, that during the phonation of both vowels and consonants the soft
palate is applied to the posterior pharyngeal wall, Lucae proposed {Virch.
Arch.f vol. Ixiv., 1875) to substitute the vowel a in place of the act of swal-
lowing in my method. Several weeks after the publication of Lucae, Jos.
Gruber in Vienna {Allg, Med. Z&itungt u, M, /. 0., 1875) proposed in place
of the vocal a to use the syllables hik and huh^ and sought to establish the
fact that he had discovered a new method, an imputation which was refuted
by Lucae (Canstatty Jahretbericht der get. Med,^ 1875, vol. ii., p. 505). Holt,
Tansley, and Lewi inject the air while the patient forcibly pufiGs out the
cheeks, whereby the soft palate is forced against the wall of the pharynx by
the pressure of expiration and the naso-pharynx is shut off from the lower
portion of the pharynx. That all these propositions are not new methods,
but modifications of the original, is self-evident, and are insufficient in most
cases for the closure of the soft palate.

A modification of the original method, which I proposed, is very useful in
practice, and consists in this, that while the air is being forced into the naso-
pharynx the patient inspires through the nearly closed lips or through a
short piece of rubber tube held between the lips. By this means the naso-
pharynx is closed, and at the same time the canal of the Eustachian tube is
widened by the traction of the soft palate backward. Although in general
this modification is of less value in its therapeutical effect than the original
method, still there are cases in which the air cannot be forced into the middle
ear either during swallowing or phonation, but diuing a strong inspiration it
enters freely. This modification should therefore always be tried where the
method fails during the act of swallowing. The entrance of air into the
cavum tympani is made much easier during catheterization by a sharp in-
spiration through the mouth.

Concerning the practical value of these modifications in the position of the
palate during the application of my method, simply blowing into the naso-
pharynx may be used, especiaUy for children, who cannot be induced to
perform the act of swallowing. The entrance of air into the middle ear will,

• Behrend's Journal JUr Kinderkrankheittn, 1864.
t CentralblcUtJUr die mecL Wissenschafi^ 1865.

Digitized by VjOOQIC

politzeb's method. 119

in that case, be much easier if the child cries during the pressure of air.
When the closure of the palate is effected by phonation of a vowel, the air
will very frequently not enter the middle ear at all, or only with very slight
force. The weak pharyngeal closure is easily forced open by the current of
air, and the resistance in the Eustachian tube is only shghtly lessened. The
same holds good also of the closure by means of the consonants ^, 7c (hih,
kuk), although here the soft palate is pressed more closely against the
l^iarynx wall by means of the base of the tongue. The results are somewhat
better when single words are used — the patient pronouncing such words as
Komg, Barique, etc., during the propulsion of air. The closure of the naso-
pharynx lasts longer, and the air is more surely forced into the middle ear
than when short syllables are used. In all these modifications the air will
enter the middle ear with less force and fails more often than by swallowing,
during which a more marked widening of tube takes place than in other
movements of muscles of the palate. This may be proved in the simplest
manner by the already described experiment of holding a vibrating tuning-
fork before the nostrils ; its sound will not be increased in any way by phona-
tion of either vowels or consonants, but during an act of swallowing, however,
a considerable increase in the sound of the tuning-fork will be perceived in
both ears. The dilatation of the Eustachian tube during the application of
my method is of the greatest importance from a practical view. In diseases
of the ear combined with great resistance in the tube, where currents of air
are effective only when they act powerfully upon the walls of the middle
ear, the entrance of air is rendered possible chiefly by the material widening
of the Eustachian tube during the act of swallowing.

Indeed, it has been shown that even in cases in which air cannot be pro-
pelled into the tympanic cavity, when the closure of the palate is effected by
phonation of vowels or consonants, a striking improvement in the hearing
will immediately follow if the method is appUed during the act of swallowing.
But even in those cases in which a certain increase in the hearing distance
takes place by inflation during the phonation of vowels and consonants, a
still more considerable improvement will generally follow the method if
applied during an act of swallowing. In general one should use the method
with swallowing by preference, and only occasionally the modification with
phonation or inspiration. An extensive use of phonation instead of swal-
lowing means the sacrifice of the therapeutical effect for the sake of con-
venience. Cases in which the air will not enter the middle ear by means of
the method with swallowing but still succeeds by phonation are very rare.
A similar extraordinary action is also seen with the Valsalvan method, but
in spite of that, we are familiar with its inferior therapeutic value.

'Rie most frequent cause for air not entering the middle ear by my method
is excessive swelling and narrowing of the isthmus of the tube or stopping
with a tenacious plug of mucus. Boosa succeeds in such cases by syringing
out the naso-pharynx, after which air will enter by my method. With such
hindrances I often found that the method with swidlowing was successful
nly after a few unsuccessful attempts had been made by inspiration or
phonation, or when, as recommended by Gbmperz, a long rubber tube was
inserted to near the ostitmi pharyng. tubs.

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120 THERAPEUTIC VALUE OP POLITZBR'S METHOD.

On the Therapeutic Value of the Author's Method {Politzerizing) as
compared with the Valsalvan Method and Catheterization.

In order to judge of the therapeutic value of the different methods
of forcing air into the middle ear it must be understood that in
treating middle ear diseases by tke air-douche it is not only necessary
that air is forced into the cavum tympani, but the benefits, apart from
the amount of pressure, depend upon the impulse of the stream
of air. Experience shows, in fact, that in middle ear catarrh a
strong, quick stream of air forced into the middle ear produces
a much more noticeable improvement in hearing than several weak
impulses which are gradually increased. The greater the impulse
of the entering air, so much more will the membrana tympani and
chain of ossicles, which were retracted by the middle ear inflamma-
tion, be forced outwards, and the amount and duration of improve-
ment in hearing will be in proportion to the amount the ossicles are
approximated to their normal position. For the therapeutic effect
of the impulse imparted by the entering current of air speaks the
fact that through repeated forcing of air into the middle ear with
a strong impulse, generally better results are obtained than through
currents lasting for some time with a constant high pressure, as can
be produced with the double balloon or air-pump.

As to the effect of Valsalva's method in comparison with mine, experience
shows that in cases of catarrh with swelling of the mucous membrane of the
tube Valsalva's method is only partially successful or entirely fails. In the
same case by my method the air enters the middle ear with full force and
greater therapeutic effect. The therapeutic value of Valsalva's method in
comparison with mine is therefore very much less.

My method has also the important advantage over the Valsalvan, that the
congestion of the vessels of the head which occur during the latter is avoided.
There is no question that the venous congestion in the head which occurs
during forced expiration is not confined to certain parts of the head, but
extends to the ears, as is proved by the frequent injection of the vessels of
the membrana tympani during the Valsalvan method. The repetition of
such congestion will necessarily create a permanent hypereemia in the ear
by which not only the inflammatory process already existing in the middle
ear is increased, but disturbances of nutrition are also caused in the labyrinth.
The same is also true of the forcing of liquids by means of the Valsalvan
method into the middle ear (Gruber). In my method, however, congestion
of the vessels is completely avoided, as no action of the muscles of the thorax
is required.

To form a correct opinion as to its value as compared with catheterization,
it is necessary to consider, first, that the current of air passing through the
catheter cannot exert its fuU force on the middle ear because the point of the

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THERAPEUTIC VALUE OP POLITZEB'S METHOD. 121

instroment is not closely grasped by the Eustachian tube, thus allowing a
partial reflux of air into the pharynx, and further, that on account of the
great Mction of the air in the instrument it leaves the point of the catheter
with much reduced force. In general as the point of the catheter is directed
against the wall of the tube more than in the direction of its lumen, the
stream of air is broken and its effect in the cavum tympani is very much
weakened.

To some extent these considerations do not apply to my method, for the
Air forced into the Eustachian tube from the pharynx with a strong impulse
wiU exert an equal pressure in all directions, and will therefore frequently
penetrate more surely and with greater power into the tympanic cavity than
during catheterization. Indeed, experience shows that in many cases, where
only a moderate increase of the hearing distance is observable after the air-
douche with the catheter, a noticeable improvement will take place when air
is forced into the middle ear by my method.

These facts were confirmed by Barth (Z,f, 0., vol. xv.) by experiments witl^
the manometer, which showed that the strongest pressure in the middle ear
is produced by my method during swallowing, as the manometer in the
external meatus showed a pressure of half the air pressure used, while by
phonation and catheterization it was scarcely a quarter of the pressure used.

On the other hand, cases are observed, to be siure, in which the air cannot
be forced into the middle ear by my method, while it is perfectly successful
by means of the catheter. These cases of middle ear affection, which are
specially favourable for catheterization, are such as an excessive loosening
of the mucous membrane close a large portion of the tube from the ostium
pharyng. to the isthmus. Here the entrance of the beak of the catheter
into the tube will separate the adherent walls for a distance, and the
remainder will be overcome by the current of air which is directed imme-
diately against it. That the catheterization, in cases of defects in the palate,
by paralysis of the palatine muscles and other anomalies of the naso-pharynx
which hinder the act of swallowing, is more appUcable than my method
needs no comparison.

As regards therapeutic value, my method of inflating the tympanic
cavity is rarely less effective than the air-douche with the catheter,
And is frequently even more so, possessing several advantages over
•catheterization. These are :

1. The simplicity of its application, which enables the prac-
titioner who is not familiar with catheterization to effect, in many
cases, the permeability of the Eustachian tube, and to treat with
success a nmnber of affections of the middle ear.

2. The possibility of injecting air into the middle ear in the treat-
ment of many cases in which catheterization of the Eustetchian tube
is very difficult or impossible. The application of my method of
inflation is specially serviceable in the case of children who suffer
very frequently from great dulness of hearing in the course of acute
or chronic naso-pharyngeal catarrhs, with hypertrophy of the

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122 THEBAPEUTIO VALUE OF POLITZEB's BCETHOD.

tonsils, owing to excessive swelling of the mucous membrane of the
Eustachian tube and effusion in the tympanic cavity. The method
can also be applied in* the congenital or acquired deformities and
diseases of the naso-pharynx {vide p. 90) which prevent the intro-
duction of the catheter. But even when the nasal cavity is normal,
this method should be exclusively employed for effecting the per-
meability of the Eustachian tube in persons who object to the
introduction of the catheter, in nervous individuals, in aged people,
and in convalescents from severe illness, in whose cases the per-
meability of the Eustachian tube requires to be established on
account of accumulation of secretion in the middle ear, but
whose weakness and irritability do not allow the use of the
catheter.

3. The application of my method should be used in all those cases
in which catheterization of the Eustachian tube can be dispensed
with. If it is, therefore, necessary to effect the permeability of the
tube by a current of air, this method is always to be preferred to
catheterization, because thus the unpleasant sensation caused by
the latter proceeding is avoided, the local irritation of the mucoua
membrane of the tube by immediate contact with the catheter does
not take place ; and, lastly, because the permeability of both
Eustachian tubes can be effected simultaneously. But I must
repeat here most emphatically that it frequently happens that
catheterization of the tube, as a diagnostic and as a therapeutic
agent, cannot be replaced by any other method, especially if the
catheter is required as a conducting-tube for the injection of fluids
and for the introduction of bougies into the middle ear.

4. My method has also the advantage that, on account of its easy
application, it is well adapted for self-treatment, especially in those
chronic affections of the middle ear, in which, after the surgical
treatment has terminated, inflation of the middle ear is from time
to time necessary to retain the improvement effected in the hearing
and to prevent a relapse.

For the introduction of vapours into the middle ear by my method, the
previously described volatilizer (p. 112) is used, the front piece of which, with
a short piece of rubber tube, is introduced into the anterior portion of the
nose. For rapidly -evaporating drugs, as sulphuric ether, acetic ether, iodide
of ethyl, chloroform, turpentine, iodine, it is quite sufficient to use the pyri-
form balloon, into which a small quantity of the medicine is introduced, or
filling with the vapour from the medicine vial by aspiration. By this method
only a smaU quantity of the vapour reaches the middle ear, and hence the
operation must be repeated several times if it is required to inject a con-
siderable quantity into the ear.

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THERAPEUTIC VALUE OP POLITZBR's METHOD. 123

In conclusion, I will mention a modification of my method, which has been
reconunended for injection of fluid into the middle ear and to wash it out.
According to the proposal of Saemann,* if the rubber balloon is filled with
fluid instead of air, and this is injected into the naso-pharynx with or with-
out swaUowing, the nostrils being closed, more or less of the fluid will be
forced into the middle ear. The original proposal of Saemann was modified
by J. Gruber (1865) in that the injection was made with a syringe instead of
with the baUoon.

As to the value of these injections as a method of treating chronic middle
ear inflammations without perforation of the membrana tympanl, experience
shows that often only a feeling of fulness, uneasiness, dizziness, numbness in
the head, a sensation of warmth or a slight burning in the ear, accompanies
it. But occasionally fainting fits occur with the most intense pain in the ear,
followed by suppurative inflammation of the middle ear, and perforation
of the membrana tympani. This either passes away without further con-
sequences or may go on to chronic suppuration with destruction of the mem-
brana tympani and the ossicles, and to caries of the mastoid process and
petrous portion of the temporal bone.

Besides these unfortunate results, in nowise seldom, I have frequentiy
observed cases in which injection into the middle ear for the cure of in-
flammation has been accompanied or followed by an increase in the deafness
and in the subjective noises. A steadily and rapidly progressing aggravation
was most strikingly apparent in those cases in which, after the injection of
the fluid, pain in the ear was felt, and where considerable engorgement of the
vessels of the membrana tympani was observable. It is probable that the
pathological changes leading to anchylosis of the ossicula are aggravated by
the irritating action of the injection on the lining membrane of the middle
ear, and that the union of the ossicula with the walls of the tympanic cavity
is only accelerated thereby.

This method of injection leads, especially in affections of one ear only, to
very grave consequences, because not infrequentiy the fluid injected into the
naso-pharynx penetrates chiefly into the normal ear on account of the slighter
resistance offered to it, and produces a reaction there which is much greater
than that produced by the fluid in a diseased ear. I have frequentiy seen
patients, previously affected on one side only, who during treatment after this
method were seized with an incurable affection of the middle ear on the other
side.

More favourable results are achieved by this method when the membrana
tympani is perforated, because the fluid entering into the middle ear can flow
off into the external meatus. Its use is only allowable when there is perfora-
tion of the membrana tympani of both sides, for in affections of one side
only, in spite of the bending of the head to the affected side, the fluid is often
forced into the normal ear, causing an acute inflammation there. Saemann's
injections, modified by Gruber, possess also the decided disadvantage that
their application is unpleasant to most patients, as, even more frequently than
with Weber's nasal douche, there occurs pain in the forehead, in the occiput,

• Die Wa»$erdouche der Ewtachian OhrtrompeU, eine ModificcUion des PotUzer*-
9clien Vtr/ahr€n$, Deutsobe Klinik, 1864.

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124 THBBAPEUTIO VALUE OF POLITZEB's BCETHOD.

and not unfrequently also in the upper jaw, lasting several hours, an
unpleasant burning sensation in the pituitary membrane, and a tickling
and choking in the throat.

In order to inject small quantities of fluid into the middle ear by my
method, when the membrana tympani is intact, the following proceeding is
recommended : The patient takes a little water in his mouth, and bends the
head slightly towards the affected side, when a Pravaz*s syringe ^ to 1 full of
warm fluid is injected through the nostril, and immediately followed by the
current of air from the balloon. By auscultation it can be determined
whether the fluid has entered the middle ear. Even by this procedure severe
pain in the ear often follows immediately after, for which reason it is
well at the beginning to inject only a few drops, and if this is not followed by
reaction the quantity of fluid may be gradually increased to J-1 syringe full.

My method may be used in perforation of the membrana tympani to wash
out the cavum tympani with medicated fluids or cleanse it from secretion in
the following manner: After the patient has taken a little water in the
mouth and bent the head to the opposite side, the external meatus is filled
with warm water or warmed medicated solution, and in this position the
current of air is forced into the ear. By means of the air passing out through
the external meatus often the middle ear is thoroughly washed out and
medicaments are able to penetrate into the middle ear more easily.

Methods of Examination and Treatment of the Middle Eab
through the extebnal meatus.

Barefaction and Condensation of Air in the External Meatus,

The therapeutic effect of the air-douche can in many cases be
increased by rarefying the air in the external meatus, as through
aspiration of the air the membrana tympani and ossicles are brought
nearer to their normal position, and at the same time the increased
pressure on the labyrinth is diminished. The condensation of air is
seldom used alone for therapeutical purposes, but more often in
combination and alternating with rarefaction in the so-called
massage of the ossicles (Delstanche), which is used in adhesive
processes in the middle ear and in sclerosis of the mucous membrane
of the cavum tympani vdth rigidity of the articulations of the
ossicles.

a. Barefaction of Air in the External Meatus.

Geland in 1771 recommended the sucking of the air from the external
meatus for therapeutic purposes, but it was later forgotten until Moos brought
the method of rarefaction of air in the external meatus into use again as a
means of treatment. The method formerly recommended, with a syringe
provided with an olive tip, works too energetically, as it may produce ecchy-
moses in the external meatus and on the membrana tympani, or even produce

Digitized by VjOOQIC

BABEFACTION OP AIR IN THE EXTERNAL MEATUS.

125

rupture of the membrane. The method of rarefaction recommended by
Lucae with a fungoid-shaped balloon is too inconstant, and requires too
much time. To Charles Delstanche we owe the * rarefacteur ' (p. 80), with
which repeated rapid aspirations may be made. A frequent adjunct to thera-
peutic methods is found in the * masseur * (Fig. 82), lately invented by
Ch. Delstanche, which consists of a metal tube 4|
cm. long and 2} cm. in diameter, enclosing a
smaller tube which acts like a yalve to a syringe.
The recoil of the valve which produces the
aspiration is accomplished by a spiral spring
between the valve and the bottom of the metal
tube. This instrument has proved in many cases
of great value in my practice. Lacking one of
these instruments, the same object may be obtained
by a rubber tube 30 cm. long, connecting an olive
tip to fit hermetically into the external meatus,
with a strong balloon, 6-7 cm. in size, or with
the ordinary large rubber balloon. The aspiration
is accomplished in this manner: The balloon is
compressed and the olive tip inserted into the
external meatus, when the balloon is allowed to
slowly expand. This procedure may be repeated
4-5 times at one sitting.

Barefaction of air in the external meatus
is indicated : 1. In all catarrhs of the cavum
tympani and Eustachian tube in which the
membrana tympani is retracted.

2. In adhesions between the membrana
tympani and inner wall of the cavum tym-
pani.

3. After paracentesis of the membrana
tympani to aspirate serous or mucous
exudate out of the cavum tympani into
the external meatus.

4. To aspirate pus from the cavum t3rmpani into the external
meatus (E. Politzer) in cases where the injection of air by the tube
is impossible, or does not succeed, and farther, in localized sup-
puration of the cavum tympani which do not commimicate with
the tube.

5. In subjective noises in the ear, which often cease or are much
diminished and become less troublesome after its use (Hedinger).
Besides these, it often produces a noticeable subjective easing in the
head and ear in middle ear catarrh which gives this treatment a
special value in treating these diseases.

6. To relieve giddiness and attacks of dizziness following increased

Fio. 82.— Massbub of

C^S. DSIATANOHB.

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126 CONDENSATION OF AIB IN THE EXTEBNAL MEATUS.

labjrrinthine pressure. This may be produced either by the product
of disease in the middle ear or through a pathological process in the
labyrinth itself. Attacks of dizziness, which are brought about by
syringing the ear when there is perforation of the membrana tym-
pani, or through other manipulations of the ear, may be quickly
relieved by rarefying the air in the external meatus. Delstanche
succeeded in a case of epilepsy in stopping the epileptic attacks by
treating the disease of the ear with the ' rarefacteur.'

b. Condensation of Air in the External Meatus.

Condensation of air in the external meatus is used much less in treatment
of middle ear disease without perforation of the membrana tympani than
rarefying the air. On the other hand, in a class of cases with perforation of
the membrana tympani, condensation of the air in the external meatus gives
good results. In this method, recommended by Lucae, the condensation of
the air is accomplished in the best manner with the ' masseur ' of Delstanche
or with the balloon apparatus previously described. Through compression
of the air in the meatus it will be forced through the tube into the pharynx,
thereby the air will leave the ostium pharyng. tubse with a plainly audible
rattling noise, or, when there is very little fluid secretion, with a dry snapping
sound.

Condensation of air in the external meatus is used :

1. For diagnostic purposes, and especially to decide as to a per-
foration of the membrana tympani in cases where the opening is not
visible and the injection of air through the tube gives a negative
result. If the end of the auscultation tube is placed in the nostril
of the patient, while the patient breathes quietly through the mouth,
by every condensation of air in the external meatus the noise of the
air escaping into the pharynx will be plainly heard. When there is
still secretion in the middle ear there will be a crepitating sound,
but in a dry perforation only a dry, crackling noise (method of the
author).

2. For therapeutic purposes :

(a) In perforation of the membrana tympani to remove the secre-
tion from the middle ear in cases where neither the air-douche by
the tube nor rarefying of the air in the external meatus succeeds in
removing it. By this means the secretion will be forced from the
anterior portion of the cavum* tympani and tube into the pharynx.

{h) After paracentesis of the membrana tympani, where tenacious
masses of mucus which are hard to remove must be forced through
the tube into the pharynx.

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CONDENSATION OP AIB IN THE BXTEBNAL MEATUS. 127

(d) To wash out. the cavum tympani from the external meatus, if
this is not possible through the tube or by my method This pro-
cedure is very simple. After the cleansing of the middle ear from
secretion by means of the air-douche and syringing, the external
meatus is filled with warm water, then the olive tip of the tube is
hermetically inserted, and by means of compression of the air-
balloon the water is forced through the tube into the pharynx. To
syringe a larger amount of water through, a large syringe can be
used which is provided with an olive tip. This procedure has been
very serviceable to me in several tedious cases of middle ear sup-
puration where other methods failed.

(e) By adhesions between the membrana tympani and the inner
wall of the cavum tympani, used alternately with rarefaction of air
in the external meatus in order to increase the working of the latter.

(/) Where there are subjective noises, which are neither
diminished by the air-douche through the tube, nor by rarefying the
air in the external meatus, there is sometimes observed (although
very seldom) a decrease of the noises after the condensation of air
in the external meatus.

The condensation of air in the external meatus, as well as wash-
ing the middle ear by this means, is contra-indicated in such ob-
structions of the Eustetchian tube that the air will not pass by the
tube with a strong compression of the balloon. In these cases the
pressure exerted upon the fenestrsB of the labyrinth very often
produces great dizziness, ringing in the ears, and deafness, to relieve
which the air should be immediately aspirated from the external
meatus.

(^) Barefying and condensing the air in the external meatus.
The use of both methods following quickly after each other, called
by Delstanche ' massage of the articulation of the ossicles,' produces
an increased movement of the chain of ossicles, whose movements
are diminished either by rigidity of the articulation, or through
adhesion. This method is specially adapted for imperceptible
adhesions in the cavum tympani and in the simple sclerosis of the
mucous membrane of the middle ear.

C. Tests fob Hearing.

The tests for hearing are of the greatest importance in the
diagnosis of the diseases of the ear; for they serve not only to
determine the extent of the disturbance of hearing, but not un-
frequently also to localize the affection, inasmuch as in cases in
which the other objective methods of examination give a negative

Digitized by VjOOQIC

128 TESTING THE SHAEPNESS OP HEABINO FOR SIMPLE TONES.

result, we are enabled to judge whether the anatomical cause of the
functional disturbance has its seat in the apparatus for the con-
duction of sound or in the nerve apparatus. But they are also of
special value because by means of them, while the patient is under
observation, we can note the course of the disease, and also the
result of treatment.

As our ear perceives not only the wa^es of sound, transferred
immediately from the air to the sound-conducting apparatus, but
also the vibrations transmitted through the cranial bones, the power
of perceiving waves transmitted in both ways must be tested
separately for diagnostic purposes.

A. Testing the Acuteness of the Perception of Sotmd-waves trans^
mitted throtigh the Air to the Membrana Tympani

1. Testing the Sharpness of Hearing for Simple Tones.

(a) Testing for the Acuteness of Perception for the Watch and
Acoumeter. — The expedients hitherto in use for testing the function
of hearing, the watch, the tuning-fork, and speech, have proved
deficient for the exact testing of the acuteness of perception of the
organ of hearing.

To test the acuteness of hearing for simple tones the watch* has-
until very recently been used for the production of sound. As,,
however, different watches vary considerably as to the pitch and
intensity of their sound, it is clear that the results of testing with
different watches must also be different, and that they are therefore
not suitable for a precise indication of the acuteness of hearing.

These imperfections have lately induced me to attempt the con-
struction of a new acoumeter, giving a definite volume of sound,,
intended as a substitute for the watch as a test of hearing.

This acotuneter (Fig. 88, actual size) consists of a horizontal steel cylinder
(c)y 28 mm. long and 4*5 mm. thick, connected by means of a tightly -fitting
screw with the perpendicular vulcanite colunm (^, /). Above the place of
attachment of the cylinder the percussion-hammer (^, e), which can be
tinned round its axis, is fastened in an oval orifice of the vulcanite colunm,
and produces the tone by falling upon the steel cylinder.

As the intensity of the sound depends on the height from which the per-
cussion-hammer falls, to produce in all instruments an equal height, a small
piece of vulcanite {d) fiumished with a soft india-rubber plate is fixed at the
posterior periphery of the coliunn as a check, upon which the posterior short
lever of the hammer is pressed. Hedinger has the hammer moved by clock-

* As Oscftr Wolf quite correctly remarks, the tickiDg of a watch is not a noise^
but a sound having a distinct pitch.

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TESTING THE A0UTENES8 OF HEABINQ FOB SIMPLE TONES, 129

work ; Barokhardt-Merian, after the method of NefiTs hammer, has it raised
by an electric current. At the superior and inferior extremities of the
column are two flat semicircles (6, a), by which two fingers may grasp the
instrument, the superior semicircle for the forefinger and the inferior for the
thumb. Below the superior semicircle, parallel with the axis of the per-
cussion-hammer, there is a ring on the vulcanite column, into which a pin,
having a round metal plate attached (t), can be inserted. This last con-
trivance is for testing the perception of the cranial bones by bringing the
metal plate into contact with the temple or with the mastoid process while
the meatuses are closed. In the same manner, in cases where the tone of
the acomneter is not heard even on the closest proximity, the round metal

Fig. 88.— The Univkbsal Aooumetbb designed bt the Authob.

plate is brought into contact with the orifice of the external meatus, to find
whether the tone of the acoumeter is perceived by contact.

'Hie cylinder is tuned to c and gives the sound of a loudly-ticking watch.
An exact tuning of the cylinder is produced by boring out, and its tone is
indicated by blowing into the mouth of the cylinder. It is evident that the
instrument, as a universal acoumeter, will only fulfil its object if all the parts
in every instrument are exactly alike and each instnunent exactly tuned.
In more severe deafness, where the acoumeter is not heard, I often use the
metronome.

While testing the hearing with the acoumeter, just as with the
watch, the direction of the instrument to the external orifice of the
ear must be considered, as the acuteness of hearing is materially
modified by the position of the origin of sound to the ear. As a
rule, the tone will be heard more intensely and also at a greater
distance if the line connecting the external orifice of the ear and the

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130 TESTING THB AOUTENEBB OF HBABINQ FOB SIMPLE TONES.

acoumeter is not perpendicular to the lateral portion of the head,
but is directed more forwards. In case of repeated testing the
acoumeter should therefore always be moved and fixed in that
direction.

To estimate the acuteness of hearing exactly, a centimeter-
measure is used, which is held horizontally and touches the head
immediately below the lobe of the ear ; but care must be taken to
avoid contact of the acoumeter with the measure, on account of
the immediate conduction of the vibrations to the cranial bones.
In every consulting-room, moreover, either on the floor or on the
wall, a meter-scale should be marked off so as to be able to estimate
exactly the acuteness of hearing for greater distances as well.

Ea^h ear must be separately tested in regard to the acuteness of
hearing ; for which purpose, during the examination of one ear the
meatus of the other is closed with the moistened finger. The
hearing-distance is measured by gradually bringing the instrument
nearer to the ear in the direction of the measure, until the patient is
able to give the exact number of strokes of the acoumeter. To
check the statements as to the perception of the tone the patient is
requested to cover the eye with the hand of the same side, so that
he cannot see the place from which the sound proceeds.

It must be stated here, in order to properly judge of the value of
testing the hearing, that the acuteness of hearing undergoes great
variations in the same person, not only on different days, but also at
different times of the day. It varies also from the influence of the
temperature and humidity of the air, as well as from somatic and
psychical conditions. It will be noticed from the testing that the
acuteness of perception of the auditory nerve shows great variations
within short spaces of time. That the sounds occurring during the
day influence the result very much is self-evident.

When testing the acuteness of hearing with the acoumeter or with the
watch, differences in the distance will be frequently observed according as
the instrument is brought nearer to the ear from without the boundary of
perception, or is farther removed from the ear after the first perception
of the tone. In the latter case the hearing-distance is ahnost always greater
than in the former. The cause of this, in my opinion, is that by approaching
the ear with the instrument not heard as yet, the extremities of the auditory
nerve, which are at rest, require a greater amount of sound to distiu'b their
eqmlibriiun, and that therefore the origin of sound must be brought nearer
to the ear to irritate the auditory nerve ; while by withdrawing the origin
of an aheady perceptible sound from the ear the auditory nerre, being in a
state of irritation, is still kept irritated by vibrations of lesser intensity, and
the sound is perceived at a greater distance.

The average distance at which the acoiuneter may be heard by a large

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TESTING THE A0UTENES8 OF HEABINQ FOB SIMPLE TONES. 131

number of normal ears in a noiseless room, as tested by Hartmann, Ohimani,
and the author, was 15 m. According to the proposition of Knapp and Prout
the relative proportion of the normal hearing power when it is heard at 1 m.
is 1^, when heard at 10 cm. it is ^'J, at 8 cm. it is ^%^, According to the
experience of Bezold and myself the distance at which the tone of the aeon-
meter can be heard remains more in proportion to that of speech than the
distance for the watch. However, we frequently see cases where a great dis-
proportion exists between the two distances. In so far as there is no direct
relation between the hearing distance for the acoumeter or watch and speech,
but often a great disproportion, the testing with the acoumeter or the watch
has only a relative value. An advantage of this method of testing is in cases
with such a slight amount of disturbance of hearing that it can scarcely be
detected even by whispering, but is discovered by testing with weaker sounds.
Although there are frequent exceptions, yet in many cases a judgment as to
the general improvement may be made by the increase of the hearing distance
for the acoumeter or watch.

The acoumeter of Hartmann, Dalby, Cazzolino, Gradenigo, and Urban-
schitch, made after the principle of the sonometer of Hughes, in which the
striking of a Neef's hammer is conveyed to the ear by a telephone, and by
means of changing the induction coil gradually made weaker or stronger, I
have not tested in practice, as the strength of the stroke varies with the
filling of the element. Besides this it possesses, as all acoumeters do, the
&ult that we cannot judge, from the increase of the hearing distance for the
tone of the acoumeter, as to the increase of the hearing distance for speech.

(6) Testing of the Perception of Different High Notes Conducted
throttgh the Air. — The equipment of the specialist for this purpose
consists of the following : a series of tuning-forks, different high-
toned whistles, a series of Konig's steel cylinders, and different
musical instruments.

Tuning-forks. — In the testing of the hearing for diagnostic pur-
X>oses, the examination with the tuning-fork has a prominent place,
especially since such progress has been made during the last few years
in the combined examination with high and low-toned tuning-forks
for bone and air conduction, in the differential diagnosis between
middle ear and labyrinth affections.

The contradictory statements which result from the testing of hearing by
different authors undoubtedly occur from the want of unity in the methods
employed and the varying styles of tuning-forks used. A unanimity of
method in the testing of hearing, as well as the use of the same form of
trming-forks and instruments, appears therefore very desirable, and should
be done to avoid irregularities in the results.

While some otologists consider a complete octave series from G-^=64
vibrations to c^ = 16,884 vibrations, in all 9 tuning-forks, as sufficient for
diagnostic purposes. Moos uses tuning-forks through 8 octaves, A^-g^,

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132 TESTING THE ACUTENE88 OF HEABINO FOB SIMPLE TONES.

and Bezold eight with movable damps : contra G with 82 vibrations contra
A, the E» A, e, h, gS and sharp,* and besides these a deep organ pipe with
687^, a higher with 1,760, and lastly, a Galton whistle, which will be de>
scribed later. With this apparatus (by moving the clamps on the timing-
forks) every tone from contra C to the highest perceivable tone on GhJton's
whistle, about 9-10 octaves, may be given. This apparatus is specially suitable
for finding breaks in the scale of perception. Each ear must be tested
separately for the upper 5 octaves, but for the lower 8 octaves it is un-
necessary to stop the other ear.

For the diagnostic piurposes of the practising physician, to test the percep-
tion for the upper, middle, and lower tones, three tuning-forks at least are
necessary— C = 128, c« = 612, c* « 2,048.

In most tuning-forks upon striking, especially upon a hard substance,
besides the fundamental tone there are a number of ringing over-tones which
tend to destroy the effect of the examination. To remedy this I proposed the
use of clamps on the prongs of the tuning-fork which can be moved when
wished and fastened by a screw. Later I have used tuning-forks without
the 'clamps, having the prongs filed down near the place where they bend
thinner than at their extremity. In these tuning-forks, when struck on some
soft substance, there are no over-tones perceptible. In the small £lake*8-
tuning-forks, to produce a clear ground tone, the ends of the prongs must be
very much thickened. Lucae uses a small English tuning-fork provided
with a scale on which by moving the clamp an increase of the tone can be<
made up to one octave.

In testing the perception for the timing-fork through the air, the
decrease of the hearing distance of the diseased ear is determined
as compared with the normal hearing distance. The method of
testing the acuteness of hearing according to the time it is heard
was brought forward by Conta.t The best tuning-fork for this
purpose is c^ (512 v.), which is made to vibrate by moderately
striking one of the prongs on the palm of the hand, or a piece of
wood covered with leather and held before the ear of the patient
imtil he says he can hear it no longer. As quickly as possible it is
then brought near our own ear (or if a one-sided affection before the

* As in most text-books the nmnber of vibrations for the different tones is not
correctly g^ven, I wiU add here a table from Appun, in which the number of vibra-
tions for the pure tones is given.

C-* = 82

D.« = 86

B.« = 40

C-» = 64

D.» = 72

B.i = 80

c =128

d =^144

e =160

c» = 256

d>=288

•>=820

c* = 612

d* = 676

•• = 640

C» = 10M

d» a 1162

•• = 1280

o«=r2048

d* = 2304

•• = 2660

c* = 40««

d« = 4608

•• = 6120

C = 8192

d« = 9210

•• = 10240

0'» 18384

d'» 18482

•' = 20480

P-« = 42,„
P-' = 86,„

t = 170,..

f* = 841,..

f = 682...

£• = 1866,..

£• = 2710,,.

£• = 6421,,,

£• = 10842,, 4

V = 21684,..

Q'* = 48

A.» = 6S„.

G-' = 96

A.> = 106,..

g =192

a = 818,..

g» = S84

»» = 420...

g« = 768

•• = 868,..

g» = 1686

a^ = 1706,..

g* = 3072

a* = M18,..

g« = 6144

•• = 6826,..

g- = 12288

•• = 18668,,.

g' = 24676

a' = 27806,,.

H-« = 60
H-> = 120
h =240
h>=480
h« = 960
h^Bi9a0
h* = 8840
h^ = 7680
h*= 16360
h' = 80720

t Arch. Ohrenb. Bd. i. S. 107.

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TESTING THE AOUTENESS OF HEABINO FOR SIMPLE TONES. 133

other ear of the patient), and the difference of time noticed between
the perception of the diseased and the normal ear. This method
can give no pretension to precision, for in repeated testings the
difference in time of perception between the diseased and normal
ears shows great variations, and farther, it is not in proportion with
the disturbance in hearing. Nevertheless, we can use it with the
other methods of examination to verify an increase of hearing during
the treatment, that is, to determine an increase or decrease of
hearing by later examinations.

In an affection of both sides, to prove the difference in the per-
ception between both ears, the vibrating tuning-fork (c^) is changed
from one ear to the other at short intervals, being held as nearly as
possible at the same distance on each side. Generally the tuning-
fork will be heard the faintest by the ear which has the greater
deafness ; the opposite is seldom the case. In slight disturbances of
hearing the difference in the perception of the two ears must be
tested by vibrations which are as weak as possible, and the difference
in time also noted. By this method of testing it is very often
noticed, especially in affection of one side with increased tension
in the sound-conducting apparatus, that the tuning-fork is perceived
^, J, sometimes even a whole tone higher by the diseased ear, but
seldom lower than the other ear.

The testing of the perception of low and high tones conducted
through the air has recently received a new importance, which it
rightly deserves, for the differential diagnosis of middle ear and
labyrinth affections. By a large amount of investigation, the result
of which I published in the Archives fur Ohrenheilkundt vol. vi.,
1871, 1 proved by experimental examination on the cadaver that in
obstacles to the conduction of sound in the middle ear, generally
high tones are better heard than low ones. For this reason, testing
with high and low tones appeared to be suggested. Lucae first
called attention to the diagnostic value of testing with low-toned
tuning-forks. He found that in middle ear affections, where the
hearing power for speech was very much decreased, low-toned
tuning-forks are only very faintly heard, or not at all ; that, on the
other hand, in labyrinth affections, even where the hearing power is
very much decreased, the lower tones of the tuning-fork are very
well heard.

From these facts Bezold formed the conclusion that the sound-
conducting apparatus participates only in conducting the waves of
sound in the lower portion of the scale, and that for the upper
portion of the scale it is superfluous. The perception will be the
more decreased by affections of the sound-conducting apparatus the

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134 TESTING THE ACUTENESS OF HEABINO FOB SIMPLE TONES.

lower -we go in the scale. The failure of the lower tones is therefore
very important for the diagnosis of middle ear affections, especially
when other symptoms fail

Although clinical observation also gives that, in general, in middle
ear affections, high tones are better heard than lower ones, still, on
account of the frequent exceptions, it is only to be depended upon
in connection with the general result of the examination of the
patient. Positive results are only given of the presence of hindrances
to sound conduction, as with these it is very exceptional that low-
toned timing-forks are heard far down in the scale. Less dependence
can be placed upon the testing with high tones, as in middle ear
affections vrith greatly diminished hearing, the perception for the
upper tones of the scale may also be lacking (Burckhardt-Merian,
Bohrer). On the other hand, in marked cases of disease of the
auditory nerve, the perception for the lower tones may be entirely
wanting, while, according to my own observation, very often high
tones, up to nearly the limit of the capability of perception, are
distinctly heard.

For the testing of the perception of the lower tones, c s 128, ia suf&cient
for the examination of most cases, but in some cases C-^ » 64 and G-^ = 82
should be used for examination. For the testing of the perception of the
higher tones the timing-forks should be used, c^ or c^ (2,048 and 4,096), and
for the testing of the upper part of the scale Galton^s whistle (brought into
use by Burckhardt-Merian in 1878) is used.

Galton*s whistle consists of a smaU, covered, cylindrical whistle which is
lengthened and shortened by a valve moved with a micrometer screw. The
lower portion of the valve is in connection with a hollow cylinder which
extends over the cylinder of the whistle. On the side of the whistle is a scale
to show the tens, and around the hollow cylinder a scale to show the single
nmnbers. The blowing on the whistle is done by a small rubber balloon
connected with it. According to Biurckhardt-Merian the GhJton whistle has
a compass of more than the three uppermost octaves with 6,481-84,000
vibrations to the second. This instrument is specially suited for testing the
capability of perception for the high tones. Above the limit to which the
perception of our auditory nerves responds for the highest notes, vibrations
are proved by the response of a sensitive gas fleune.

Besides the Galton whistle, Blake, Burckhardt-Merian, and Bohrer recom-
mend for testing the upper limit of the perception of hearing, a series of
Konig's cylinders of 20,000 to 100,000 vibrations in the second with intervaLs
of 5,000 vibrations. The diameter of the sounding tubes is about 20 mm.,
and their lengths vary according to the different tones of the series. Appun*s
apparatus for testing the upper tone limit consists of 11 tuning-forks of 2,000-
50,000 vibrations (Kessel). The forks are set in vibration with a violin bow.

Testing with high-pitched tuning-forks and with Galton*s whistle will only
give a good result when the dif&culty of hearing affects both sides and has pro-

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TESTING THE ACUTENESS OF HEABING FOB SIMPLE TONES. 135

greased to a considerable extent. In unilateral ear affections, or where both
are affected but one only to a slight degree, the results of testing are not
reliable, as in spite of carefully hermetically closing the normal or less
affected ear, the perception of the high tones cannot be excluded from the
closed ear. In certain cases the perception of the examined ear is tested
by localizing the tone and conducting it to the ear with a long speaking
tube.

The perception for high tones, especially those of Galton's whistle, de-
creases in old age. Between 60 and 70 years of age g^ will not be heard
constantly (Moos).

For testing the perception of lower and higher tones, as well as proving
the presence of gaps in the sccde of tone perception, a musical instnunent
may be used, a piano or harmonium being the best.

(c) The Author* s Test to prove the Perception of the Vibration of
the Tuning-fork through the Eustachian Tube, — The experiment,
which I first brought forward (p. 65), of holding a vibrating tuning-
fork (c* = 512 V.) before the nostrils during an act of swallowing,
when it will be more loudly heard in both ears, is suitable for a series
of cases : (1) to prove the permeability of the Eustachian canal ; (2)
to diagnose an obstruction to the conduction of sound in the middle
ear. The results of this experiment are :

1. In middle ear affections of one side with impermeability of the
Eustachian tube, resulting from swelling of its mucous membrane
covering, through clogging with secretion or a true stricture, the
tuning-fork c^, when held before the nostrils, will in most cases be
heard only in the normal ear. If with difficulty of hearing limited to
one side, a diagnosis of middle ear disease is made by examining
the membrana tympani, or through Weber's or Binne's test, and the
tuning>fork before the nostrils is heard louder in the normal ear, an
impermeability of the Eustachian tube on the diseased side is very
probable.

When in such cases the tube is made permeable by means of the
catheter, or my method, and the tuning-fork is held before the
nostrils, it will be heard louder in the diseased ear. This may be
either transient or remain. This symptom is a favourable prog-
nostic sign, in so far that the restoration of the permeability of the
Eustachian tube, which was formerly closed, may be reassured.

2. In those unilateral middle ear affections, where the Eustak)hian
tube is not obstructed, a c^ tuning-fork held before the nostrils will
often be heard louder in the diseased ear (as in Weber's test).
Exceptions are not rare. When, therefore, in unilateral difficulty of
hearing, and by ocular inspection, or through Weber's or Einne's
test, a hindrance to sound conduction is demonstrated, if the tuning*
fork (c^ is hesurd louder than in the normal ear it is certain that

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136 TESTING THE HEABINO-POWEB FOB SPEECH.

the Eustachian tube of this side is permeabla This symptom
occurs most often in unilateral, chronic, so-called dry middle ear
catarrh, and quite often in those middle ear processes due to
prevalent inflammation, especially with a dry perforation and small
amount of swelling of the mucous membrane of the middle ear.

In ear affections of both sides, where one ear is more affected
than the other, this test seldom gives the previously described
result.

3. After middle ear suppuration with persistent perforation of the
membrana tympani, with the formation of cicatrices on the membrana
tympani, and with thin cicatrices which are stretched before the
ostium tympani tubsB, occasionally during swallowing the sound of
the tuning-fork may be heard by the examiner as much increased
through an auscultation tube placed in the ear of the patient.

4. In unilateral labyrinth affections, where the objective examina-
tion and all the symptoms leave no doubt of the presence of affection
of the auditory nerve, the c^ tuning-fork will be heard only in the
normal ear, as well during swallowing as when the tube is in a state
of rest.

2. Testing the Hearing-power for Speech.

Oscar Wolf* did the great service, by means of a large number of
thorough investigations, of establishing the key-note of the different
sounds of speech, as well as the distance at which they could be
distinguished. The results which he gave serve as a foimdation
for the testing of hearing by means of speech.

According to Wolf, speech has a compass of five octaves, from c to c*.
The deepest tone is that of B lingual, the highest is S. The greatest strength
of tone and the most timbre belongs, according to Wolf, to the vowel A,
which can be heard at 252 m., and the smallest to the H sonnd, heard at
8'4 m. distance. He calls the following self -toned : B sound lingual, B, K,
T, F, S, Sch, and G soft in contradistinction to L, M, N, and W, which borrow
their sound from the adjoining vowels.

Fixing the hearing-distance for speech with a view of estimating the
amount of disturbance of hearing is more difficult than testing the hearing-
distance for a constant sound. During a careful observation of this method
of testing, it strikes us at once that the vowels are generally perceived more
surely and at a greater distance than the consonants. For this reason patients
frequently hear only the vowels of a word of several syllables, and when
repeating what they have heard pronounce another word which contains the

* Spraehe und Ohr : ActMtisch-phygiologiache und pathologische Studien (Braun-
schweig, 1871), and Neue Untersuchimgen fiber H(frpnifung und ff&rstfhrungen ; A./,
A^en- und Ohrtnheilkf voL iii.

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TESTING THE HEARINO-POWEB FOR SPEECH. 137

same vowels but different consonants (for instance *Yater* instead of
* Wasser ;' * Gabel ' instead of * Tafel '). It is also observed that those words
in which vowels of a clear sound, A, E, and I, occur are more easily perceived
than those which contain the more or less dull vowels 0 and U. For this
reason it comes that the self -toned consonants are heard with more difficulty
than those which borrow their sound.

The recognition of separate words at a certain distance depends also on the
arrangement of the vowels and consonants, as also on the rhythm and
cadence of the syllables, so that many words are heard and understood
at a disproportionately greater distance than others.

Other facts which preclude the exactness of testing the hearing for speech
are the differences in volume and timbre of the voice, as well for ordinary
conversation as whispered speech in different individuals, and the impossi-
bility, even with the most careful practice, of governing the speech so as to have
the same strength of voice on different days.* The results of the testing
of the hearing for speech cannot therefore be absolute, but only have a
relative value.

In spite of the various imperfections thus seen to be associated with the
testing of hearing by speech, we yet look upon it as an indispensable test in
the estimation of the disturbance of function and of the results of treatment.
Observations show, however, that there often exists a striking disproportion
between the hearing-distance for simple tones and for speech, and that not
unfrequently during the treatment of aiural patients the hearing-distance for
simple tones increases to a considerable extent, while the distance for the
miderstanding of speech has only shghtly increased, and vice versa. This
shows that results obtained by testing the hearing with the watch, or other
origin of sound, do not indicate the degree of the functional distiurbance for
speech. But as our endeavour in the treatment of functional disturbances
is mainly centred in the re-establishment or improvement of the power of
hearing speech, the application of speech as a means of testing cannot under
any circumstances be dispensed with.

To ascertain the hearing-distance for speech (quantitative test,
according to O. WoU), the ordinary conversation is used as well as
whispering. By the latter the result of the test is so much more
fiure as the ordinary volume is diminished by the speaking, and the
ear receives soimd-waves differing from each other much less in
volume than those of loud speech (O. Wolf).

Inasmuch as the testing by whispering gives much less difference
in the distance for single words than in loud speech, where the
space is large enough to allow it, one should test the hearing-
distance for both whispering and conversation. No positive relation
exists between them, and the perception for whispering gives no
exact statement as to the perception for conversation. The ascer-

* Tbe proposition of Lichtwitz, to use Edison's phonograph in testing for speech
(Congr^ iaternat Otolog. et LaryngoL, 1889), has not, up to the present, found a
place in practice.

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138 TESTING THE HEARING-POWER FOR SPEECH*

taining of the hearing-distance for the latter appears very important^
as the oonversational tone alone gives a measure of the hearing in
practical life. In severe grades of disturbance of hearing, the con-
versational tone can alone be used for testing.

According to Hartmann and Siebenmann, the average normal
hearing-distance for whispered speech in a room as noiseless as
possible amounts to 25-26 meters, during the ordinary noise of the
day to about 20 meters, a distance which agrees with that (60
Frankfort feet) stated by Wolf {I c). R. Chimani found it in a
quiet hall of the Vienna Garrison Hospital to be a distance of 21
meters. Bezold, with his weak, slightly accentuated whispering,
found the distance by children only 17-20 m.

Besides the quantitative testing of hearing, it is necessary,
according to 0. Wolf, for a differential diagnosis to use the qualitative
test for speech. He proceeds accordingly to estabhsh the hearing
distance by comparing the perception for high, medium, and lower
tones of speech, as compared with the normal perception. Accord-
ing to the method proposed by Wolf,* one tests the patient first by
means of the self-sounding consonants alone, R lingual, B, K, T, P,
8, Sch, and G soft, as well as the very deeply whispered U ; besides
this, words of speech are used in which the testing sound is very
prominent. The sound-borrowing letters, L, M, N, and W, may be
disregarded while testing. The S-sound with the greatest number
of vibrations will be heard very badly, or not at all when there are
hindrances to sound-conduction, the Sch-sound will be heard a little
better. Failure to hear the F-sound occurs in labyrinth disease,
according to Wolf. The deepest tone of speech, according to the
same author, is the lingual R (with 16 double vibrations) ; the
perception for it is often lacking in defects of the membrana tympani.
The failure of perception for the lingual R and the whisper n» when
the conduction apparatus is intact, with other symptoms, may be
considered as an important point for the diagnosis of a labyrinth
affection.

The list of words proposed by O. Wolf and Schwabach as suitable for
testing are divided into three groups :

Group I. (a) High pitched and far-reaching hissing sounds, S, Sch, and
Gsoft:

Strength of tone for the normal ear, Sch-sound . 200 paces.
„ „ „ S-sound . 175 „

„ „ „ GorChsoft . 180 „

Test words: Messer, Strasse (spoken like Schtrasse), Sage, EesseU
Strauch, Schlage.

• Ck>mpare aIso Schwabach, Archivf. Ohrenheilkunde, voL xxxi, p. 82.

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TESTING THE HEABINO-POWEB FOR SPEECH. 139

(6) High, weak F-soimds, F and V.

Strength of tone of F-sound 67 paces.

Test words : Feder, Frankfurt, Ferdinand, Friedrioh, Fuss.
Group II. Explosive sounds of medium pitch, B (pitch e^), K (pitch d^,
T (pitch d' sharp) :

Strength of tone : E- and F-sound . • • • 68 paces.

„ „ B-tone 41 „

Test words: Teppich, Tante, Kette, Kappe, Teller, Tinte, Bitte,
Kuppe.
Ghroup III. Deep tones : U (pitch P), R lingual without voice-sound (pitch
of the prevailing tones, C'~'=16 double vibrations in the second).

Strength of tone : U (whispered) . . . .50 paces.

„ „ B (spoken at end of tongue) • 41 „

The U is only suitable, as well as the other vowels, to be used in

whispered speech for differential diagnosis.
Test words : Buhe, Bruder, Ruhrort, Beiter, Buhm, Bauch, Beise.

When certain words fiure repeatedly used for testing, they will be
easily guessed by the patient, so that errors may arise in judgment
as to the improvement. To guard against this, other irrelevant
words should be inserted among them. The testing with whole
sentences is not advisable, as the hearing of certain words will lead
the patient by combination to guess the sense of the whole. The
testing with numbers is very imperfect, as by repeated tests the
whole number is guessed from hearing the vowel.

For the judgment of improvement in the hearing of speech during
the treatment, it is necessary that there be a great difference in
distance. As, however, many words are heard at widely different
distances than others, it is better at the first examination to fix the
distance at which a certain number of words can be heard, and to
make a note of them, and to compare the hearing-distances in future
examination for the same words. With children easily compre-
hended words should be used, and limited to four to five in
number, as children easily become tired and restless, and do not
listen to the words pronounced to them.

When testing the acuteness of hearing for speech, special care
must be taken that the spoken words are not read by the movement
of the mouth, as many patients, especially those who have been
hard of hearing since childhood, possess a particular skill in reading
the lips.

Each of the ears must be separately tested, the one being turned
directly towards the speaker, while the other is closed as completely
as possible with the moistened finger-tip. In cases of one-sided
deafness, special care must be taken to close the normal ear as nearly
hermetically as possible, because words spoken moderately loud in

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140 . TESTING THE HEAKINQ-POWBB FOB SPEECH.

the neighbourhood of the diseased ear may be easily heard by the
normal one if insufficiently closed, and in this manner mistakes may
take place. In such cases, speaking loudly in the neighbourhood of
the patient must therefore be avoided, and it is advisable, in cases
in which it is desirable to ascertain that the patient has really heard
the speech with' the' diseased and not with the normal ear, to test
the hearing with both meatuses closed. If after the diseased ear
has also been closed, speech is still heard at the same distance as
before, it may be assumed with certainty that the sound enters into
the normal ear ; if speech is not heard, there can be no doubt that
it had been heard by the diseased ear before it was closed.

In cases of severe deafness, to determine whether speech is heard by
means of the membrana tympani and ossicles or through the cranial bones
and Eustachian tube, a speaking tube should be used with the funnel held
outside of the patient^s hearing distance. If speech is not heard through the
tube, then sound-conduction by means of the ossicles does not exist. To
demonstrate if it is heard by means of the Eustachian tube, in repeated
examinations within the hearing-distance the mouth and nostrils should
occasionally be firmly closed. It is certain that the patient hears by means
of the tube if words which are clearly heard at a certain distance after
closing the mouth and nostrils can no longer be perceived.

Besides the separate examination of each ear it is advisable to
find the combined hearing distance for both ears for speech, sis this
is not in relation to the results of the separate examination in
most oases, and further, this hearing distance is of most importance
in practical life. The testing is performed as follows : the patient
stands opposite to the physician, facing him directly and with his
eyes directed downward to the floor. I hold this method of testing
the hearing-distance for speech, before and after treatment, as the
more important, as it gives the surest judgment of the amount of
improvement in hearing.

I will here note a few observations as to the disturbances of hearing for
speech which wiQ be met with. Most patients, when their deafness is not
too great, understand speech which is not too loud but clearly accentuated,
better than too loud, quickly spoken words. Female voices with clear, high
timbre are better imderstood than flat, low-toned male voices. Habit plays a
very important part; the speech of relations and acquaintances is much
easier heard than that of strangers. Words which are used in daily life are
heard at a greater distance than unfamiliar ones ; a foreign idiom is heard
with much more difficulty than the local speech. In cases with otherwise not
very marked disturbance of hearing, the deafness of many patients for cer-
tain special words is remarkable. Exceptionally, with slight deafness, speech
is sometimes heard better at some distance than close at hand. In some
very rare cases whispering is heard at a greater distance than loud speech

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TESTING WITH THE WATCH AND THE ACOUMETEB. 141

(Borekhardt-Merian). Musical tones are better perceived than speech (p. 62).
For this reason people with even a high degree of deafness can enjoy a
concert, while they are totally unable to hear the spoken drama.

B. Testing the Perception of the Waves of Sound condticted to the
Ear through the Cranial Bones.

1. Testing with the Watch and the Acowneter,

If a vibrating body is brought into contact with the cranial bones,
the vibrations will be communicated to all parts of them, and there-
fore also to the ear. These vibrations reach the labyrinth in two
difEerent ways, viz. (1), by immediate conduction from the solid
parts to the labyrinth, and (2) by transmission from the cranial
bones to the membrana tympani and the ossicula, to be conducted
by them to the labyrinth (Cranio-tjnmpani Conduction. E. H. Weber,
Lucae).

The perception of the waves of sound, conducted from the solid
parts of the head to the ear, is modified in many ways by morbid
changes in the organ of hearing. Clinical experience sufficiently
confirms this, and attempts have often been made to utilize these
changes for diagnostic purposes. These changes in bone conduction
for the watch do not give the important differential diagnostic
symptoms which were imputed to them by the older ear specialists.
Nevertheless, testing the conduction through the cranial bones must
not be omitted, for if not in all, at least in a great number of cases,
important indications as to diagnosis and prognosis can be obtained
by it.

For testing the perception of sound through the cranial bones, the
watch, the acoumeter, and the tuning-fork have hitherto been used.

Testing with the watch, as a weaker instrument, cannot be
dispensed with in cases in which it is required, not only to ascertain
whether vibrations are perceived through the cranial bones at all,
but also to find out the extent of the decrease in perception. It is
therefore to be recommended that, besides testing with my acoumeter,
use should also be made of a low-ticking watch. If such a watch is
perceived, it may be inferred that the perception of the Auditory
nerve is intact. If the watch is not perceived, while the acoumeter
is heard distinctly, a decrease in the power of perception may be
inferred ; if even the strokes of the acoumeter are not at all noticed,
a severe affection of the perceptive apparatus may be assumed.

Testing with the watch is effected, after the meatuses have been
closed by the patient, by pressing it first to the temples, then to the

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142 TESTING WITH THE WATCH AND THE ACOUliETEB.

mastoid processes, or upon the teeth. At this point the watch is
heard loudest, less loudly at the forehead, the parietal bone, and
the occiput. In the same manner testing with the acoumeter is
carried out by bringing its metal plate into contact with the above-
mentioned points. In the greater portion of cases the ticking will
be heard by the ear imder examination, and occasionally even by the
opposite ear.

As is well-known, the power of perception through the cranial
bones is diminished in old age to a varying degree. This is not due,
as was previously supposed, to the decreased conduction of the
cranial bones, but chiefly to the material changes which the auditory
nerve undergoes through senile degeneration. After the flftieth
year cases are not infrequent in which a low-ticking watch is not
heard through the cranial bones ; after the sixtieth year the cases
are rare in which it is still heard. In aural patients over fifty years
of age, who do not perceive soimd through the cranial bones, the
same importance cannot be attached to those imperfections as in
younger individuals.

The utilization of this method of testing as regards diagnostic and
prognostic inferences can only go so far as that in a case of middle
ear affection which has been diagnosed from objective symptoms, a
complete failure of perception for the watch or acoumeter by bone
conduction proves an accompanying lessening of the perception in
the auditory nerve. This method has a positive value, according to
my observation, only in such cases where the ticking of the watch is
well perceived by means of bone conduction, although the perception
for the watch, the acoTimeter (air-conduction), and speech is markedly
diminished. In these cases we may say, although only in connection
with the results of the tuning-fork tests, very probably the deafness
is due to a hindrance of sound-conduction, and not to a labyrinth
affection. This method of testing has also a practical value inas-
much as the prognosis of a case where the perception for a weakly-
ticking watch by bone conduction exists will be much better than in
one where the perception is diminished or completely extinct. The
return of the perception by bone conduction, which has been lost
through acute middle ear inflammation, concussion of the laby-
rinth, or syphilis of the labyrinth, is a very favourable prognostic
symptom.

In conclusion we will mention the rarely observed intermittent perception
through the cranial bones. The phenomenon that on some days the watch
is heard well through the cranial bones, while on others the perception is
completely wanting, occurs in acute as well as in chronic affections of the
middle ear, but is more rarely seen in labyrinth affections. In such cases the

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TESTING WITH THE TUNING-FORK, 143

fluctuations in the power of perception of the auditory nerve are produced
partly by abready existing anatomical changes, partly by an alteration of the
tension in the tympanic cavity, and by its secondary influence upon the
labyrinth.

2. Testing with the Tuning-fork.

(a) Testing the Duration of Perception through the Cranial Bones.
— Schv^abach first found that in hindrances to sound-conduction,
following disease of the external or middle ear, a vibrating tuning-
fork brought into contact with the cranial bones, would be heard
longer than by the normal eax. On the other hand, in disease of
the auditory nerve apparatus, the perception is shortened in com-
parison with the normal ear. We possess by this means, although
the symptoms are not always present, a method to prove a changed
perception of the auditory apparatus in pathological cases.

The tuning-fork which is most used to test for bone conduction is
c* (512 V.) ; to test for the higher tones different tuning-forks, from
c* to c^, are used. The deep-toned tuning-forks are not suited for
this examination, as the greater excursions of the prongs of the fork
are transmitted as a concussion to the cranial bones, and may be
mistaken by the patient for a sensation of sound. For this reason
one should use a well-made tuning-fork, c*, which is not only free
from over-tones, but also communicates no concussion to the cranial
bone&

The duration of perception through the bones of the head is
proved in two ways, according as, in special cases, a shortened or
lengthened perception is sought for. In the latter case, the
examiner places the vibrating tuning-fork on his own mastoid
process. At the moment when he fails to hear it, he places it on
the mastoid process of the patient, and notes the number of seconds
which it continues to be heard. If the duration of perception is
found shortened, the tuning-fork is first placed on the mastoid
process of the patient, and, at the moment when he fails to hear it,
brought directly in contact with the mastoid process of the examiner,
and the number of secopds noted until it ceases to be heard. In
one-sided ear affections, or where' both are affected but one to a less
extent than the other, this method will give an unreliable result, as
the perception in the better or normal ear will lead to improper
answers by the patient. It is to be noticed that, according to
Siebenmann, the duration of perception for the lower tones of the
tuning-fork are shortened by Valsalva's and Toynbee's experi-
ments.

Although, from my observation, this method cannot be relied upon

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144 TESTING WITH THE TUNING-FORK.

alone for dififerential diagnosis between middle ear and labyrinth
affections (inasmuch as in middle ear disease which is complicated
by labyrinth affection the duration of perception is very much
shortened), as a diagnostic and prognostic sign, it is an important
symptom. As a diagnostic symptom it supports the conclusion of a
hindrance to sound conduction when there is a lengthened duration
of perception (negative Einne), and on the other side, when there
is a shortened perception (positive Einne) with great deafness for
speech, the diagnosis of disease of the auditory nerve is made more
certain.

With lengthened duration of perception the prognosis in regard
to the course of the disease will be much better than in those cases
in which it is much shortened. In the latter case a disease of the
auditory nerve will be so much the more certain the greater the
difference in time between the loss of perception on the mastoid
process of the diseased and of the normal ear.

(6) Wehet's Test, — Testing of the lateralization of the perception
of the tones of the tuning-fork from the median line of the skull,
E. H. Weber first found that a vibrating tuning-fork set upon the
skull will be pre-eminently hesurd in that ear the external meatus of
which is closed by the finger. The increased sound perception is
produced (1) by the increased resonance of the external auditory
meatus ; (2) by reflection of the waves of sound transferred through
the cranial bones to the air of the external meatus upon the mem-
brana tympani and the ossicula ; (3) by the altered tension of the
membrana tympani and the ossicula* (Politzer). According to
Bezold, the excessive tension in the bands of the ossicular chain in
middle ear affections produces the increased perception for the
vibrations of the tuning-fork through the cranial bones.

The Weber test has proved, in combination with other methods
of testing, a valuable assistance in the diagnosis of ear diseases.
Clinical observation shows that in the majority of cases of unilateral
ear disease, where the sound conduction to the labyrinth is hindered
by pathological changes in the external meatus or middle ear, a
vibrating tuning-fork placed on the middle line of the skull will be
heard most markedly in that ear where the pathological change
occurs. It must of course be understood that the labyrinth is not
at the same time affected so that the vibrations of the tuning-fork
can no longer be perceived through the auditory nerves.

The same is also often observed in affections of both ears of
different intensity, yet in these cases there are many exceptions, as

* Compare my discusnon, ' Ueber Sohalleeitaog durch die Kopfknochen * {A./,0,,
vol i., p. 318).

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TESTING WITH THE TUNING-FORK. 145

the toning-fork may be heard better by the less affected ear
instead of by the more affected one.

On the other hand, in disease of the auditory nerve apparatus,
provided it is not complicated by an affection of the external or
middle ear, the tuning-fork, when held on the middle line of the
skull, will be heard more loudly in the normal ear.*

The best tuning-fork to use for Weber's test is c^ (512 v.) which is free
from over-tones. When the results are not satisfactory lower toned forks
may be used, but higher toned tuning-forks should not be used for this t^st,
as they often give an exactly opposite result to c* and lower toned ones.

The Weber test is carried out as follows : holding the tuning-fork
by the handle, and striking one of the prongs on an upholstered
piece of wood, or on the palm of the hand, the handle is set
on the median line of the skull. As the test from the vertex
often gives no positive result, it is better then, in such cases, to
press the handle either on the median line of the upper lip, agwnst
the incisor teeth, or on the median line of the lower jaw, from which
place the increased sense of sound will more often be correctly
located than from the vertex (Edwin v. Milligan).

In questionable results the soimd will prevail in one ear distinctly if the
end of an otoscope is inserted into both ears. The answers of the patients
are of most importance when the tone perception predominates in one ear in
unilateral ear affection, it is of less importance when both ears are affected.
In these cases, especially with double chronic middle ear affections, thd
tuning-fork is heard equally on both sides, or more distinctly on one side
from the vertex and on the other from the maxillee or base of the nose.f

* The increased perception of the tuning-fork through the cranial bones in the
affected ear in unilateral ear affections, was known to the older ear specialists, but was
regarded as due to obstruction of the external meatus, tympanic cavity and labyrinth
(£. Sohmalz, Erfahrwng iiber die KrankheiUn des Oehdrs, Leipzig, 1846). My
observations for thirty years show, that in cases of undoubted labyrinth disease, as
in apoplectic Meniere's disease, in auditory paralysis from concussions of sound, in
cases of syphilis of the labyrinth, etc., if they are not combined with a middle ear
^iy^MiA, the tuning-fork (c*) without exception is localized in the normal ear. This
&Mt is not refuted by the observations of Jaoobson, that in a traumatic labyrinth
affection, the tuning-fork was heard more loudly in the affected ear, as in such cases
a complication may exist, of a change in the chain of ossicles produced by the trauma.
As little dependence can be placed on the cases observed by Burokhardt-Merian and
Hartmann, where the cochlea were exfoliated on one side with lateralization of the
tone of the tuning-fork in the diseased ear, for these cases are always associated with
middle ear disease, and the perception is received through the saccule of the vestibule
and the ampullae.

t If, as I first showed, the finger be placed in the meatus of the normal ear in
unilateral hindrance to sound conduction, the increased sound perception will spring
from the affected ear to the normal one, and upon removing it will return to the
affected side again. It is, therefore, proved that the preponderance of sound per-
ception in one ear is able to suppress the sound perception in the other ear, in spite
of an equal conduction of sound to both ears.

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146 TESTING WITH THE TUNING-FORK.

From the parietal eminence the timing-fork may be heard in the opposite
ear even when normal.

The Weber test possesses a diagnostic value only in those cases
where the positive statement of the patient shows that the vibrations
of the tuning-fork from some one point on the middle line of the
skull preponderates in the affected or more affected ear. We can
then conclude that there is a hindrance to soimd conduction. On
the other hand, the statement that the sound of the tuning-fork
predominates in the better hearing or normal ear has little value,
as this may occur either in middle ear or labyrinth affections. In
the latter case, it is only to be considered a diagnostic symptom
when in connection with a series of other symptoms which will
be stated later.*

The results of testing with the watch and tmiing-fork are often opposite,
as on that side where the perception of the tuning-fork, from the vertex,
prevails, the watch pressed upon the temple of the same side will not be
heard, or only much weaker than in the other ear. The reason for this,
according to my view, depends in greater part on the different intensity of
sound of the watch and tuning-fork, as often in such cases if a metroncone,
the strike of which is like the ticking of a watch many times increased, be
placed upon the vertex, it will be heard more loudly in the diseased ear. The
difference in pitch of the tones should also be considered, as in failure of
the upper tones, the high over- tones of the watch will not be heard (Bezold).

(c) Binne's Test. — Combined testing of air and bone conduction. —
If one holds a vibrating tuning-fork on the mastoid process or other
portion of the skull until the tone is no more heard, and then holds
the prongs near the ear without striking again, it will be heard
anew in the normal state of the ear. This is called the positive
Einne test.

In a paper on physiologyf in 1855, Binne brought forward this test as of
general diagnostic value, for he stated that in those disturbances of hearing
in which the timing-fork is heard through the cranial bones longer than
before the ear, a disturbance of the sound-conducting apparatus exists. This
is known as negative Binne or, as the author proposed, * disproportionate.*^
Where, on the contrary, the timing-fork is perceived longer before the ear
than through the cranial bones (positive Binne) it indicates, according to
Binne, a disea.se of the auditory nerve apparatus. To Lucae belongs the
honour of applying this test in practice, which was unnoticed until then. Its

* Compare Gell^, De la valeur aemioiique de Vepreuvt du diapason vertex,
Congresabericht, Basel, 1885.

t Prager Vierte^ahresschri/t, vol. i., 1865, p. 72.

X I proposed this name (aiufallender), as it is clearer for those not specialiBts than
the word ' negative Binne,' by which a positive result, however, is understood*

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TESTING WITH THE TUNING-FORK. 147

diagnostic significance has been demonstrated by means of sections from
Politzer,* Luoae, Bezold, and others.

Although the diagnostic value of this test is limited, yet in a series of cases
it affords vGduable assistance in so far that often, when other symptoms are
lacking, Einne's test will establish the diagnosis between middle ear and
labyrinth disease. This test must always be considered in connection with
the general results of the examination, especially to the amount of deafness
for speech, the duration of perception for the tones of the tuning-fork
through the bone (p. 148), and to the perception of high and low tones.

The general results of this test may be summed up as follows :

1. Eiime's test is of important diagnostic assistance in those cases
of chronic middle ear affections with marked deafness,! in which
the diagnosis cannot be made by other methods of examination.
The Einne test is in the majority of these cases negative, provided
that no deeper complication, with an affection of the auditory nerve,
is present.

2. The negative Einne speaks so much the more for hindrance to
soimd conduction the greater the difference in time between the
duration of perception for the tuning-fork before the ear and from
the mastoid process. This diagnosis v^ill be supported by the
failure to perceive low tones and the relative better perception for
the higher tones ; farther, by the lengthened perception of the tone
of the timing-fork through the cranial bones (Schwabach). In
tmilateral deafness the negative Einne will be supported in the
diagnosis of hindrance to sound-conduction if at the same time, in
Weber's test, the perception is localized on the diseased side.

3. In middle ear affections in which there is only slight or a
moderate amount of deafness, Einne's test has only small diagnostic
value, as in the majority of these cases it gives a positive result.
This is very often the case in purulent middle ear inflammation,
with perforation of the membrana tympani.

4. In middle ear affections with a slight amount of deafness, the
diagnostic value of Weber's test is to be placed above the Einne
test.

6. In old individuals, in which the duration of perception through
the cranial bones is shortened (Liebermann), Einne's test often gives
no positive result.

* Bmaner, Z, /. O. vol. xiii, p. 263 ; Bezold, Erkldrungaversuch, Z. VerhaUen d.
Luft tmd Knockenleitung beim Hinne^sehen Versuch, Muhchen, 1885 ; Roosa,
Archives qf Otology, 1884 ; Emmerson, Z. f. O. voL xiii., p. 63 ; Schwabach, Z.f, O.
▼oL xiv., p. 64 ; Politzer, Berichl d. Vera, suddeuischer und sckweitzer Ohmdrzte,
Munchen, 1885 ; Eitelberg, Z,/, O. vol. xvi ; Rohver, Monograph, Zurich, 1885.

f According to Lucae, Rinne*8 test can only be relied upon when the hearing
distance has decreased to Im. for whispering.

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148 TESTING WITH THE TUNINO-POBK.

6. In cases of chronic middle ear disease which are complicated
by affection of the auditory nerve, the result of Eicne's test often
remains undecided.

7. When, in severe deafness, the Binne test gives a positive
result, it leads one to diagnose an affection of the auditory nerve,
especially if at the same time the results of the examination, causes,
course, and symptoms speak for disease of the auditory nerve
apparatus. The diagnosis will be supported by the marked de-
crease of perception for the higher tones, with, at the same time, a
relatively good perception for the lower tones and a shortened
duration of perception for the tuning-fork through the cranial bones.

8. Clinical observation shows that the Binne test may be positive
in middle ear affections with great deafaiess, and negative in severe
forms of labyrinth disease. This fact does not detract from the
general value of this test, if it is used in combination with other
methods of testing to arrive at a diagnosis.

The c^ tuning-fork is specially suited for Binne*s test, yet one can use
besides c' and c^. High-toned tuning-forks may interfere with the result
in so far that the air conduction cannot be entirely eliminated. Testing
with low-toned forks is to be avoided, as the concussion on the cranial bones
may be mistaken for a tone perception. With every tuning-fork the duration
of Binne's test is to be established in seconds by the average results in
normal ears.

The test is performed in two manners: 1. The vibrating tuning-fork is
held before the ear until the patient says he fails to perceive it, when imme-
diately the handle is placed on the mastoid process, and the patient signifies
when the vibration ceases. The difference in time between the perception
from the air and through the mastoid process must be measured in seconds
and noted. This procedure is generaUy observed in hindrances to sound
conduction. 2. The vibrating fork is first placed upon the mastoid process,
and as soon as it fails to be heard is placed in front of the ear, and the dif-
ference in time between the perception upon the mastoid process and before
the ear is measured in seconds. This is the method of testing for positive
Binne. If in the same case different results are obtained from testing by
the two methods, the average should be taken as the result (Bing). Things
which interfere with the examination by Binne*s test are the occasional after-
tones of the tuning-fork in the ear and perception of the timing-fork in the
opposite ear. The latter may generally be avoided by holding the tuning-
fork parallel instead of at right angles to the mastoid process.

(d) Oellfs Test. — Pressions centripites. — If in the normal ear the
air be compressed by means of Siegle's speculum, or with a baUoon
provided with an olive tip, the tone of a tuning-fork placed on the
vertex will be greatly diminished. This decrease is the result of in-
creased labyrinth pressure, as by this means the membrana tympani

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TESTING WITH THE TUNING-FOBK. 149

and the chain of ossicles, with the plate of the stapedius, are
pressed inward. There is no question that the tension of the sound-
conducting portion produces the weakening of the sound perception.
If in a case there is hindrance to sound conduction — for example, an
anchylosis of the stapes — the tone of the tuning-fork, according to
Grell6, will remain unchanged during the test ; but if the labyrinth is
affected and the stapes movable, the tone of the tuning-fork will be
diminished by every condensation of air in the external meatus, as
in the normal ear. Besides this, in labyrinth affections a more or
less pronounced dizziness will be produced by the increased pressure
in the labyrinth.

Cessation of perception for the tuning-fork and unreliable state-
ments of the patients interfere with the application of this method
of examination.

Grell^'s test is generally only of value in the severer grades of
deafness, as it is only in these that a positive result is given (even
in these not constantly). This test is of little value in deafness of
slight degree, as in slight middle ear affections the tone of the
tuning-fork is diminished when the air is condensed in the external
meatus, as in labyrinth affections. Gell^'s test agrees with the
result of Rinne's experiments very often (according to Eohrer in
seven-tenths of the cases). Where, by means of Rinne's test alone,
or in combination with other methods, a diagnosis is positively
made, the use of Gell^'s test may be dispensed with. On the other
hand, it is to be remembered that in certain cases where the other
tuning-fork tests give no certain result in severe grades of deafness,
the Gell6 test will occasionally give a positive indication. I will here
mention the diagnostic point, that in cases where a slight pressm e
produces dizziness, the diagnosis of auditory nerve affection is
sustained. Dizziness and diminution of the tone of the tuning-fork
in Gell^'s test may, however, be absent in labyrinth affection.

There remains yet to mention Bing's method of differential
diagnosis between middle ear and labyrinth affections, which con-
sists in the fact that a vibrating tuning-foric held upon the mastoid
process after the tone ceases to be heard, by closing the external
meatus with the finger will be heard anew. In pathological
cases, according to Bing, one may be certain of hindrance to sound
conduction if, on closing the meatus, the tone of the timing-fork is
not heard again; if it is heard again after closing the meatus, it
signifies an affection of the labyrinth. Only in cases of severe
deafness from hindrance to sound conduction does this method give
a positive result; in slight cases of middle ear affections and in
disease of the labyrinth it generally fails.

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160 TESTING WITH THE TUNINO-POBK,

Corradi (A, f. 0., vol. xxxii.) found that the tone of a tuning-fork oould
again be heard after the perception had ceased by removing it from the
mastoid process and again replacing it in the same position. This returning
again of the tone-perception after it has disappeared should be repeated (3-4
times) by removing and replacing the timing-fork. The first tone-perception
Corradi called primary, the following secondary. In difficult hearing the
presence of secondary perception indicates the presence of a middle ear
afifection, and the lack of it indicates a labyrinth afifection. The confirmation
of these statements must be waited for.

I will here make a few remarks regarding the understanding of speech
through the cranial bones. I have ascertained that by filling both meatuses
with glycerine and closinre of the mouth and nostrils, whole sentences will be
understood at the distance of i m. (A,f. 0., vol. i., p. 850). The pathology
of middle ear affections, especially anchylosis of the stapes, shows us the
fact that, if the vibrations of the membrana tympani and the ossicula are
obliterated, articulated tones are still heard. That in these cases the waves
of sound are transmitted through the cranial bones and not by the means of
the air in the cavum tympani to the labyrinth is proved by ^e fact that
words spoken through the speaking-tube are not understood, but words spoken
loudly near the ear are still heard.

That the understanding of speech as well as the hearing of musical tones
in hindrances to sound conduction in the middle ear by means of the cranial
bones and other solid portions of the body is possible, is shown by the cases
reported in the older literature of ear diseases. To these belong those persons
of difficult hearing who hear a series of musical notes only indistinctly and
without connection, while if they are in connection with the source of the
tone (for example, connected to a piano by means of a rod held between the
teeth) whole tunes are heard as plainly and distinctly as when their hearing
was normal. I have seen cases of severe deafness resulting from a chronic
thickening of the lining of the cavum tympani who only hear speech, with
their eyes closed, if the hand of the speaker be placed upon the head or
shoulder.

I will only mention here a method given by me to test the condition of
tension of the sound conduction apparatus by means of an auscultation tube
with three branches as well as the interference-otoscope of Lucae for the
same purpose. As even in the normal condition, both membrana tympani
reflect the waves of soimd with imequal intensity, and other conditions, as
different width of the meatuses and unequal position of the tip of the tube,
etc., go to influence the results of the examinations, the value of this method,
which is very good for some cases, is much dixninished. For the more
complete understanding of the subject refer to my paper on sound conduction
through the cranial bones {A, f, 0., vol. i.), and to the paper by Lucae
(A.f. 0., vol. iii., p. 186).

Dr. Bing has given for severtJ years an assistance to diagnosis which he
calls the ' entotio ' use of the speaking-tube. He designates thereby the
speaking in the funnel of a speaking-tube the other end of which is
connected with the cavum tympani directly by means of fitting into a
catheter introduced in the Eustachian tube. In this way the waves of

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METHOD OP EXAMINING THE PATIENT. 151

BOTind pass through the speakmg-tabe, catheter, and Eustachian tube into
the cavum tympani, where they reach the footplate of the stapes and the
fenestra rotvinda, and by them are communicated to the fluid of the labyrinth
and the auditory nerve. In a case where speech is not heard through a
speaking-tub^ in the external meatus but by the * entotic ' use of the same
is easily understood, according to Bing there is certainly a hindrance to
sound conduction in the malleus or incus, and the footplate of the stapes is
freely movable in the fenestra ovalis.

C. Method of Examining the Patient.

A thorough examination of the patient is an indispensable postu-
late for the making of a correct diagnosis and determining the
prognosis and the proper treatment. Examination of the patient is
divided into the history and subjective symptoms of the patient, and
the objective examination.

The record of the statements of the patient in regard to the
course of the disease is very important. While in certain cases the
diagnosis may be made without a detailed record of the history by
means of the objective examination of the patient> it is in the
majority of cases absolutely necessary to take into consideration the
history of the pathological changes, as it is only by it, in connection
with the objective results, that a diagnosis of the affection as well
as a prognosis is rendered possible.

When inquiring into the history of a case, it is specially important
from a prognostic point of view to find out the duration of the ear-
disease, as the prognosis will be generally the more favourable the
shorter its duration. In cases in which disease of the ear has
suddenly developed without any previous affection of this organ
with striking subjective symptoms, or when the affection is produced
by some prominent cause (acute eruptive fevers, typhoid, trauma),
we generally receive reliable statements regarding the commence-
ment of the disease, but many patients are not even able to fix the
date of the beginning of their disease approximately. The latter
happens especially in those cases of unilateral insidious affections of
the ear, which are developed without striking subjective phenomena,
without pain or subjective noises, and unnoticed by the patient.
These are generally dated only from the time when, during the
closure of the normal ear, the functional disturbance of the diseased
ear has been accidentally found out. But also in such cases affect-
ing both ears the functional disturbance will be noticed only when
it has reached such a degree as to interfere with conversation,
especially in persons whose position or calling makes no great
demands upon their hearing, and who therefore hardly notice any

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16S HBTHOD OF EXAMININO THE PATIENT.

trifling impairment. The commencement of a disturbance of hear-
ing, which has already existed unnoticed for a long time, may also
be dated from the appearance of the subjective noises ; indeed, not
unfrequently patients are examined who state that their ears have
been afifected for only a short time, while objective examination
shows extensive loss of substance, chalky deposits, and cicatricial
formations, which have existed for a long time without the person
in question having the least idea of any affection of the ear.

No less important from a prognostic point of view is the deter-
mination of the cause of the ear disease, as the prognosis is quite
different in genuine disease of the ear than in those produced by
scarlatina, syphilis, and other general diseases.

The diseases of the ear are either produced by influences working
directly upon the ear, through general affections, or diseases affecting
other organs adjoining.

Of the causes which directly set up mischief in the ear, we must
in the first instance consider injuries, the excessive action of sound
Upon the organ of hearing, scalds, bums, frost-bite, and lastly,
vegetable parasites (aspergillus), in the external meatus.

Of the causes which come into play by means of continuity and
contiguity of tissue, due prominence must be given to the acute and
chronic naso-pharyngeal affections (hypertrophy of mucous mem-
brane of the naso-pharynx, adenoid vejgetations, polypi, ozoena, etc.)
which cause functional disturbances of varying extent by spreading
to the middle ear. A large number of the cases are produced by an
infection of pathogenic microbes, extending from the naso-pharynx,
as has been shown by recent investigation. Less frequently is the
ear affected by external disease, as, for instance, by erysipelas and
eczema of the skin of the face and head.

Among the immediate causes, even if not always demonstrable,
we must count the atmospheric influences which are commonly
called ' colds.' We are only justified in considering the ' cold ' as
the cause of the ear disease if the disease occurred shortly after the
exposure of the ear to a cold wind or cold water, or exposure of the
body to wet and cold. Patients often use the word ' cold * for an
•unknown and only supposed cause of the ear disease.

Affections of the ear are also developed sometimes in the course of
general diseases, or diseases of special organs. To the former class
belong scarlatina, measles, small-pox, typhus, syphilis, diphtheria,
mumps, rachitis, Bright's disease, diabetes, leukaemia, tuberculosis,
scrofula, acute rheumatism, and gout; to the latter, pneumonia,
puerperal processes, and a number of affections of the circulation,
euch as are caused by valvular defects, aneurism, struma, attacks of

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METHOD OF BXAMINIK6 THE PATIENT. 153

hooping-cough, gravidity, and anomalies of menstruation. Besides,
inter-cranial processes, meningitis simplex, meningitis cerebro-
spinalis epidemioa, hydrocephalus acutus and chronicus, apoplexy,
encephalitis, sclerosis of the brain, and tumours of the brain (Bene-
dikt) ; also tabes dorsalis, and hysteria, are the cause of disturbances
of hearing of different degrees, partly by the extension of the
pathological processes to the ear itself, partly by affecting the trunk
of the auditory nerve. In conclusion, we must mention certain
drugs, like quinine, salicylic acid, and others, which, when taken
internally, produce temporary or permanent disturbances of hefuring,
as also chronic poisoning, occurring in various industries, from lead,
arsenic, phosphorus, etc.

Another important cause has to be added to those already
enumerated, viz., hereditary predisposition. As is well-known,
hardness of hearing is hereditary in many families to the extent
that either all the members, or several of them, are afSicted with
it. The affection appears either in the immediate descendants, or,
according to my experience, more frequently in the second genera-
tion. But we are only justified in iissxmiing hereditary predisposi-
tion as the cause of the aural affection, when in several members of
the same family the disease of the ear has developed with similar
symptoms and without other demonstrable cause.

If, according to the foregoing, we are often enough in a position
to trace the causes of the affection of the ear to one of the above-
immed sources, we must, on the other hand, confess that very
frequentiy the cause is not to be defined. This refers not only to a
number of acute inflammations of the external and middle ear,
accompanied with free exudation, but especially to those insidious
affections of the middle ear which are developed without striking
symptoms and with a gradually progressing functional disturbance.
But this is by no means surprising if we consider that medical
science is still generally in dsurkness regarding the pathogeny and
determination of the causes of disease, especially chronic affec-
tions.

Another point to be considered during the examination of the
patient is his calling and occupation, inasmuch as in the curable
forms of acute and chronic inflammations of the middle ear, the
chances of complete recovery are much smaller in persons who are
obliged to expose themselves during the course of the disease to
unfavourable influences connected with their occupation, than in
those who are in a position to avoid any external disadvantage.

The unfavourable influence of occupation upon affections of the
ear is especially prevalent among certain classes; for instance,

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154 METHOD OF EXAMININa THE PATIENT.

coachmen, masons, tanners, fishermen, sailors, soldiers in the fields
etc. — ^in a word, among persons who are continually exposed to all
the vicissitudes of the weather. It is just as certain that the
affections of the ear, associated with subjective sensations and an
irritated or paralytic state of the auditory nerve, are influenced in a
detrimental manner by noises in certain occupations continually
acting upon the organ of hearing. We observe, for instance, in
locksmiths, blacksmiths, millers, coopers, workers in noisy factories^
and so on, in consequence of the excessive irritation of the auditory
nerve, an obstinate continuance of the subjective noises, and an
increase of the same, as well as of the deafness.* That climate, the
condition of the dwelling, the mode of life of the patient, tho
excessive indulgence in spirits, smoking and snuffing tobacooi etc.»
influence the course of affections of the ear, requires no further
proof.

It is also important to note the mode of development and the
course of an affection of the ear, as they not unfrequently permit of
a conclusion as to the nature of the disease. It is, therefore,
necessary to find out in every pase whether the disease has arisen
with acute inflammatory phenomena, or without them, with rapid
decrease of the function of hearing, or whether the disease ha&
taken a slower, insidious course, ynth gradually increasing deafness.

We must likewise learn whether the power of hearing varies to
any considerable extent or not. For experience teaches that great
fluctuations in the hearing^istance are generally observed in secre-
tive inflammations of this cavity capable of resolution ; but that in
the insidious inflammations of the middle ear, unaccompanied by
swelling and secretion, which cause permanent disturbances of
hearing by the fixture of the ossicula, the heading is subject to
only very slight fluctuations.

A few remarks may here be made from a prognostic point of view
regarding the frequency of the diseases of the ear at different ages^
and the influence of age upon the course and issue of the disease, t

* That oocupationB which are associated with continuous noise not only act un-
favourably upon already existing affections of the ear, but cause ear disease, is beyond
doubt. In the investigations which I undertook in regard to this with different
tradesmen, I found that, next to the locksmiths, coppersmiths and coopers were most
afiOicted by disturbance of bearing. Upon the latter especially, according to their
own statement, the so-called hollow stroke when hooping the casks is said to hav»
such a deafening effect, that most of them, if they remain at their trade, become
hard of hearing in time.

t Weil found among 5,905 children about 80 per cent, with deafness of different
grades, and Bezold among 3,826 children about 20 per cent, with deafness. These
have, however, only a local value, as the results of statistics for different climates
and other local peculiarities are certainly very different, which accounts for the great

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METHOD OP EXAMININO THE PATIENT. 155

Soon after birth, the transformation-process in the middle ear, the
rapid formation of mucous membrane there, and the action of
external injurious agencies upon the hypersBmic mucous membrane
of this cavity, favour the origin of inflammations. In childhood the
acute exanthemata and naso-pharyngeal affections are the chief
diseases which frequently become the source of affections of the
ear. While the frequency of ear-diseases decreases in the prime
of life, it presents again a noticeable increase in advanced age, not
only in consequence of retrograde changes in the ear similar to those
in the other organs of special sense, weakening the power of the
auditory nerve, but also frequently ovmig to the development of
chronic insidious inflammations of the middle ear leading to
thickening of the lining membrane of the tympanic cavity and to
rigidity of the articulations of the ossicula.

We vnR now describe a series of subjective and objective S3rmptoms,
the importance of which in diagnosis and prognosis must not be
undervalued.

Among the subjective symptoms which hold a prominent place in
our consideration are the subjective noises, which occur as ringing,
knocking, hissing, roaring, whistling, like boiling water, etc. Ac-
cording to my observation, nearly two-thirds of all ear patients
suffer from subjective noises in the ear, and the number who como
for treatment on account of them is very considerable. Often
objective noises (circulatory and muscular noises and mucous rales)
will be heard as blowing, snapping, and cracking sounds.

Where, according to the statements of the patients, subjective
noises exist, it should be determined whether they are unilateral or
bilateral, if they are perceived in the head or in the ear, whether
they are endurable or very troublesome, if they have a hi^ or low-
toned character, by what things they are increased, and whether
the sensation is only occasional or uninterrupted. This is important,
for my experience shows that the prognosis is much less favourable

disproportion between the Btatistics of Weil and Bezold. According to Biirkner
among every 100 cases of ear disease, 78 adults and 27 children, there are 25 per
cent, with diseases of the external ear, 67 per cent, with middle ear disease, and 8
per cent, with affections of the anditory nerve. These statistics were made by
Biirkner from the annual reports for several years of the different ear dinios and
dispensaries of Europe. They can bear no claim to exactness, however, as the
differential diagnosis between middle ear and auditory nerve affections was formerly
much less exact than at present, and some of the reports are lacking in many im-
portant details. In general, ear affections are more frequent among men than
women. The left ear is more often affected than the right ; according to Lowenberg,
unilateral ear affections among men are more often in the left, and among women in
the right

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156 METHOD OP EXAMINING THE PATIENT.

in cases with continual subjective noises than in those where no
noise occurs, or only occasionally. One should examine further if
the noises in the ear are increased or diminished by diminished
blood-pressure in the ear, during compression of the carotid ; or if
stopping the external meatus with the finger affects the intensity of
them ; whether the subjective sensations are altered by reflex action
from the cutaneous branches of the trigeminus ; also through
pressure upon the mastoid process; or irritating the skin in the
region of the ear ; and lastly, if the intensity is decreased by the
tones of high or low tuning-forks.

A more rare accompaniment of ear diseases is the pain, which is
very intense in acute myringitis, acute middle ear inflammations,
especially in children, and in oajdes of the temporal bone.

Where the patient complains of pain in the ear, we must deter-
mine if it is located in the region of the external ear or in the deeper
portion ; whether it is limited to the ear or extends outward towards
the forehead, occiput, or the region of the neck; if the pain is
increased by pressure upon the region of the ear, and how often
during the course of the disease the pain has occurred, and if it is
atypical or in regular paroxysms. Besides, it is important to
determine the cause of the pain in every case by objective examina-
tion. If we are aUe to say from an ocular inspection that there is
no inflammatory process in the ear, we should investigate whether
we have to do with a neuralgia, whether it is located in the
external meatus or in the plexus tympanicus, and whether it is a
localized ear disease, or accompanies a trigeminus or cervico-occipital
neuralgia. One should not forget in such cases to examine the
teeth, as, especially in children with carious teeth, the pain radiates
to the ear. In the same way, during ulcerative processes in the
pharynx and larynx, the pain may radiate to the ear.

To the important ear symptoms should be added dizziness, which
occurs not only in disease of the labyrinth and in cerebral deafness,
but is often observed in those affections of the middle ear which are
accompanied by increased pressure in the labyrinth. These patients
should be tested by walking with closed eyes and by turning the
body on its long axis. One should observe to which side there is a
tendency to fall, and whether by forcing air into the middle ear or
aspirating it from the external meatus, the dizziness is increased or
diminished.

Lastly, in judging of the symptoms of the disease, one should be
careful not to place too much importance on such abnormal sensa-
tions as pressure, fulness, etc., in the ear, as these are placed in the
foreground by the patient on account of their disagreeableness. To

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METHOD OP EXAMINING THE PATIENT. 157

these also belong the often unpleasant resonance of the patient's
own voice, as occurs in unilateral accretions of cerumen and in a
swollen or patulous Eustachian canal, and the painful sensation of
sound called hypersBSthesia acustica, which occurs in nervous indi-
viduals and in slowly progressing Cases of chronic ear affection with
great deafness.

Of the objective symptoms the first thing to determine is the
presence or absence of a discharge from the ears. Where it exists
we should question how long this has existed, whether it is copious
or scanty, what character it has, purulent, mucous, or bloody, with
a bad odour or not, whether it has been uninterrupted since its
start, or occasionally stops, also whether a subjective easing during
the period of stopping, or, on the contrary, pain and pressure in the
ear occurs.

Of less importance, but under certain circumstances noticeable,
are the following disturbances of hearing. To these belong the
better hearing in a noise, in a waggon, upon the railroad (Paracusis
Willisii), which occurs most frequently in the adhesive processes of
the middle ear, without secretion, and is therefore to be considered
as an unfavourable prognostic symptom. Another symptom, which
is seldom spontaneously given, but may be obtained upon question-
ing the patient, is the paracusis locaUs, or the impossibility to give
the direction of the soimd. One observes this mostly in unilateral
deafness of a severe type, and it is to be explained by the fact that
the judgment of the direction of sound is made possible only by
binocular hearing.

An estimation of the facts of the patient's history, already de-
scribed, as also of the most important symptoms of disease, taken in
connection with the results of the objective examination, should in
most cases enable one to form a judgment as to the nature of the
affection of the ear and its prognosis in any given case. It is now
only required to survey, in regard to the methods of examination
already discussed, the order of procedure in the examination and
inspection of patients.

The objective inspection of the patient conunences with the auricle,
the external meatus, and the membrana tympani. The neighbour-
hood of the external orifice of the ear and that portion of the
external meatus visible without the speculum must be examined
before the introduction of this instrument, because certain changes,
confined to this region (for example, eczema, fissures), are covered
by the speculum, and might thus be easily overlooked. After the
insertion of the speculum, the meatus is examined as to its capacity
and curvature, character of its secretion and vascularity ; and the

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158 METHOD OP EXAMINING THE PATIENT.

nature of existing obstacles, such as are caused by a natural or
abnormal secretion of cerumen, by fungi, polypoid growths, exostoses,
or other pathological processes, leading to the stricture of the
meatus, is ascertained by inspection, and eventually by probing.

If the inspection of the membrana tympani is not prevented, the
different portions of the membrane are examined in regard to
colour, lustre, transparency, and curvature, by slightly moving the
speculum. The degree and extent of the vascular injection, the
size and colour of existing opacities and chalky deposits, the form,
position, and extent of perforations, of cicatrices and atrophied
places, are ascertained, and the presence of general or partial out-
ward curvature, which may be caused by infiltration, serous and
purulent formations, as also by granulations and polypous growths,
is discovered. General or partial inward curvatures of the mem-
brane, and their relation to the articulation of the stapes and to the
inner wall of the tympanic cavity, must also be taken into con-
sideration.

The position and inclination of the malleus, the size and outward
curvature of the short process and of the posterior fold of the
membrane, the form and extent of the triangular cone of light, the
pathological changes in the tympanic cavity, the colour and extent
of exudation shining through, and in case of a perforation, the state
of the visible inner wall of the tympanum, must be ascertained. In
cases of decided anomalies of curvature of the membrane, as well as
those which appear normal, examination with Siegle's speculum, to
ascertain the tension and mobiUty of the membrana tympani, must
not be omitted.

After ascertaining the state of the membrana tympani, the function
of hearing has to be tested by first finding out the acuteness of
hearing for the acoumeter and the watch, the perception for the
tone of the tuning-fork through the air, the distance of hearing for
speech, and then the power of perception through the cranial bones
by means of the watch, the acoumeter, and the tuning-fork (Weber's
and Binne's test, duration of perception through the cranial bones).

Then follows the examination of the Eustachian tube and of the
tympanic cavity, by the Valsalvan experiment, by propelling air by
means of my method, and if these procedures give no positive result,
by means of the catheter. Here the auscultation-sounds in the
middle ear, and the changes in the membrana tympani, perceptible
after inflation, especially the change of colour and curvature of the
membrane, and the position of the handle of the malleus, must be
observed.

After examining the middle ear, testing the hearing is repeated

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METHOD OF EXAMINING THE PATIENT. 159

in the above manner to ascertain the difference in the power of
hearing before and after inflation. This is of the greatest importance
as regards both diagnosis and prognosis. For generally, if a con-
siderable increase in the hearing-distance takes place, it may be
inferred that the changes are such as to warrant a favourable
prognosis (swelling and secretion in the middle ear, anomalies of
tension, etc.), while in cases in which no improvement in the hear-
ing, or only a slight one, takes place after inflation, the prognosis
will be more unfavourable, because it may with probability be
assumed that the disturbance of hearing is due to some organized
and irremovable pathological change in the middle ear, or in the
labyrinth.

It is even as important to ascertain whether the subjective noises
still remain, after making the Eustachian tube permeable. If there
is an important diminution of them, it is a favourable prognostic
sign, in that it proves the noises to be partially dependent on changes
in the middle ear which are producing pressure upon the lab3n:inth.
When, on the other hand, after forcing the air into the middle ear,
the noises in the ear remain unchanged, we may judge that, in
most cases, there are changes in the hearing apparatus which
warrant an unfavourable prognosis.

According to my experience, great importance should be placed
on questioning the patient, whether, in troublesome pressure and
fulness in the ear, by placing his finger tightly in the external
meatus and repeated shaking, he seeks to rid himself of the dis-
agreeable feeling. We should also question the patient, especially
in middle ear affection, if he has used the Valsalvan experiment, as
patients often use it without telling the physician in regard to it.
Both manipulations have a very bad influence upon the hearing,
and the misuse of Valsalva's experiment, if the patient is not warned
in time by the physician, will produce severe disturbances in the
hearing.

In inflammation of the middle ear, especially in acute and chronic
suppuration, examination of the region of the mastoid process is
absolutely necessary, because inflammations which have extended
to that part produce palpable changes by involving the external
osseous wall, the periosteum, or the integument, changes which it is
very important to discover in time for treatment to be applied. By
a moderate pressure with the tip of the finger it may be ascertained
whether there is any enlargement of the bone, any infiltration of the
periosteum and of the skin, and whether fluctuation is present ; also
whether, and to what extent, pressure upon the bone causes pain,
in what part of the mastoid process the greatest pain during pressure

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160 METHOD OP EXAMININO THE PATIENT.

is felt, and whether or not a fistulous opening or cicatrix exists. As
in inflammation of the external meatus and of the middle ear,
especially in purulent affections, the cervical glands and the
lymphatic glands on the mastoid process are often swollen and in«
filtrated, they have also from time to time to be examined, as a
decrease in the infiltration may generally be considered as a favour-
able sign.

After this follows the examination of the naso-pharynx in regard
to congestion, swelling, secretion, growths of mucous membrane,
ulcerations, and principally in regard to the state of the orifices of
the tubes. Referring to the special division on the naso-phar3rngeal
affections for the details of the examination, we will only remark
here that rhinoscopic inspection must be made, especially when the
collective symptoms (changes in the portions of the visible naso*
pharyngeal structures, increased secretion, palpable obstacles in the
naso-pharynx, and difficulty in breathing through the nose) make
the instrumental examination advisable. In case of obstacles to the
current of air through the nose, our attention is often drawn to the
presence of a naso-pharyngeal affection by a peculiar expression of
the face of the patient, which arises from breathing through the
widely opened mouth.

But while the result of the objective inspection of the ear and the
neighbouring parts, together with the history of the case, generally
suffices for prognosis and treatment, it is often necessary also to
consider the state of the general health. We cannot, however, by
any means agree to the proposal of those specialists who urge a
minute examination of the organs of respiration, circulation, etc., in
every aural patient. Considering the amount of time which is spent
in a minute examination of the patient, and in a thorough objective
testing of the ear, such an examination of the other organs, under-
taken without a special cause, would only be an imnecessary loss of
time. The examination will therefore be extended to other organs
in those cases only in which either the patient's history {e.g.,
frequent occurrence of pulmonary catarrh, haemoptysis, palpitation
of the heart, syphilis), or his appearance, etc., make a general
investigation appear necessary.

Lastly, one should be careful in determining the treatment for
special cases, and use such treatment as has previously been tried
by experienced physicians.

For the judgment of the course of the disease, it is important to
note down the history, subjective and objective symptoms. The
most practical way of noting down these memoranda is to make use
of a special printed form, and I will here annex the one which I

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METHOD OF EXAMINING THE PATIENT.

161

^^- ^^^°"^- Name. Age, Occupation, Residence.

Diagnosis.

Duration. Cause.

Course.

Paitt

TiBnit...; Otorrho. P^^Sn S^'X

1
1

icle.

Aui

Membrana 1 Euatach. ' ., ^
Tympani. j Tube. P'^' ^^t.

Naso-
pharynx.

1 1

. i H«»rin)(-distaDce.
o PoUtz. Metb. . or Cathel

1 Air-conduction for

ter.' Tuning-fork.

Bone-conduction. Weber

1
1

Before.

After.

II
}

ly Ext.

Meatus.

ByEust.l
Tube. !

i
1

Acoum.

Watch.
Acoumeter.

1 Rinne.

IR.

Presen

Right.
1

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;

1-2

Short-
ened.

,uaicon.

Acoum.

Watch.

! High
tones.

Acoumeter.

' T U

^ -

ened.

Low
1 t«»ne8.

' 1

i 1

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Observations :

Tre

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--.- .-_

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distance i

ifter Close of Treatment.

Acoumeter.

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Whi

Digitized by VjOOQIC

162 METHOD OF EXAMINING THE PATIENT.

employ. It is reproduced here somewhat changed in shape, and
each page in the octavo shape contains two forms.* When abbre-
viations, initial letters, and certain signs are employed, which every-
one may construct according to his own convenience, the history of
a case can be completely inserted into the given space, and can be
used not only as a guide during the course of the disease, but also
for scientific communications.

* The German lithographed forms can be had in the shape of a book, firmly bound,
from Schonfeld, Wieii, at the price of 2 fl. o. W. per 500 forms.

Digitized by VjOOQIC

DISEASES OF THE SOUND-CONDUCTING APPARATUS-

SPECIAL PORTION.

DISEASES OF THE EXTERNAL EAR (AURICLE AND EXTERNAL
AUDITORY MEATUS).

I. Anomalies op Secretion in the External Auditory Meatus.

Hypersecretion of the Ceruminal ^Glands, Formation of Ceruminal

Plugs,

The secretion of the cerumen, a product of the ceruminal and
sebaceous glands, takes place chiefly in the cartilaginous, and only
to a small extent at the commencement of the osseous section
of the external auditory meatus. In normal conditions the secre-
tion is removed partly by the movements of the jaw, and partly by
various manual manipulations. Frequently, however, the cerumen
remains in the meatus, thereby forming a plug by which the canal
becomes obliterated and the function of hearing mechanically im-
paired.

Etiology, — The causes of ceruminal accumulation in the external
auditory meatus are : 1. Habitual or frequently-recurring hyperaemia
of the lining membrane of the meatus, combined with hyper-
secretion of its glandular elements. 2. Congenital or acquired con-
traction of the external meatus, preventing the discharge of the
cerumen. To the first class belongs the well-marked screw-like
twisting of the meatus (Bezold), to the latter the membranous
strictures, the hyperostoses and exostoses in the external section of
the meatus and the slit-like contraction of the external orifice of the
ear caused in old age by atrophy and shrivelling of the cartilage of
the meatus. 3. Abnormal nature of the ceruminal secretion, the
retention of a tenacious secretion, which becomes matted with the fine
hairs of the cutis, favouring the accumulation of the masses formed

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164 ETIOLOGY. — SYMPTOMS.

afterwards. 4. Improper cleansing of the external meatus, especially
in persons who usually allow, when washing, a quantity of water or
soap-suds to flow into the meatus, and then insert into the latter a
pointed piece of the towel. The liquid ceruminal secretion is
thereby pushed from the cartilaginous into the osseous section, and
is finally formed into a lump. 5. Eczema, circumscribed and
dififase otitis externa, partial or diffuse desquamative inflammation
of the cutis of the meatus, and suppurations of the middle ear, after
the termination of which a plug very often forms. 6. Foreign bodies
in the ear, on which the cerumen sticks till an occluding plug is
formed, collections of powder, coal dust, desiccated portions of
plants, etc.

Accimmlations of oenimen occur either without any other disturbance or
combined with diseases of the middle ear and of the labyrinth. In people
with sound ears the plug may attain a considerable size before the hearing
becomes notably affected. Such are those interstitial plugs which do not
completely fill up the lumen of the meatus, and do not lie upon the membiana
tympani. Mechanical disturbance of the hearing only commences when the
lumen of the auditory meatus is completely obstructed by secretion, or when
the plug rapidly swells d\u*ing washing, bathing, or perspiration ; or lastly,
when it is driven against the membrana tympani by shaking (occluding
plugs).

Symptoms, — Frequent but not constant symptoms of accumulation
of cerumen in the external meatus are : a feeling of confusion and
fulness in the ear, subjective sensations of hearing, resonance of
one's own voice, sometimes giddiness and vertigo in consequence of
the increased intra-auricular pressure, rarely mental depression
(Boosa and Ely, Z. /. 0., x.), hallucinations of hearing (Rohrer),
vomiting, and eclamptic attacks. More or less severe stinging pains
in the ear occur only when the plug is very hard, in consequence
of the pressure on the walls of the auditory meatus and on the
membrana tympani. In such cases, after removal of the accumula-
tion, there is frequently found a circumscribed inflammation of the
osseous meatus, rarely of the membrana tympani. That the
chemical quahty of the secretion can also produce pain is proved in
those cases where, after removing the thin layer of soft secretion
from the walls of the meatus, the pain stops. Habermann observed
in three cases persistent cephalalgia and trigeminal neuralgia {A. f.
0., vol. xviii.) ; Kiipper a case of brain irritation following an
epidermis plug ; Herzog a case of alteration in the action of the
heart {Z,f. 0., vol. xx.).

The disturbance of hearing varies according to the degree of
occlusion, and the apposition of the plug to the membrana tympani.

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CERUMINAL PLUGS: DIAGNOSIS. — PR03N0SIS, 165

I have never observed total deafness, even in cases of complete
occlnsion. When speech cannot be understood, it is probable that
there is disease of the middle ear or of the labyrinth. In primary
accumulations, the hearing-distance often varies suddenly, especially
when the plug swells and shortly afterwards contracts, or when it
imdergoes a sudden change of position from movements of the jaw.
In perforation of the membrana tympani the plug of cerumen
may improve the hearing by acting as an artificial membrane
(Eiesselbach).

Toynbee (I. c.) and v. Troltsch (Virck. Arch,^ vol. xvii.) record post-mortem
examinations showing enlargement of the external meatus, the formation of
apertures in the walls of the meatus, and perforation of the membraaia
tympani. Although the possibility of such changes cannot be denied, still,
judging from the reports of such conditions, I believe that in most cases they
have been sequels of an exhausted suppuration of the middle ear.

Diagnosis, — ^By examination with the speculum, and not un-
frequently also with the naked eye, the external meatus is seen to
be plugged by either a light yellow or dark-brown grea.sy mass,
glistening or dull, which, on being touched with the probe, feels
doughy, half liquid, or hard as a stone. The following may be
mistaken for ceruminal plugs : purulent masses remaining after an
exhausted otorrhoea, mixed with epidermis, cholesteatomous masses,
and dried up to a brown crust ; dried blood ; foreign bodies en-
veloped in cerumen; and often balls of cotton, which have been
pushed too far down, and became brown after a long time.

After its removal, the obstructing plug often exhibits impressions of the
external surface of the membrana tympani, the umbo, and the short process.
The mass consists either chiefly of ceruminal secretion, or in great part of
oomified epidermic cells (Wreden, Gl. J. Blake) epidermic plates closely
I>acked together or spirally arranged (Bezold), and uprooted hairs, with a
slight mixture of cerumen and cholestearine. In many cases it is less of a
hyper-secretion of the ceruminal glands than a pathological desquamation
of the epidermis of the external meatus (Lowe). The ceruminal secretion
contains different fungi (Ebert), and according to the investigations of Bohrer,
saprophytic and pathogenic bacteria.

Prognosis. — In regard to the restoration of the function of hearing,
this is favourable only when the deafness took place suddenly after
a bath or washing, because then the probable cause of the disturb-
ance of hearing would be a primary ceruminal plug. When this is
not the case, one must be very careful in giving a prognosis, in view
of the fact that accumulation of cerumen is very often associated
with the adhesive processes in the middle ear, or with disease of

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166 TBKATMENT.

the labyrinth (according to Toynbee, 160 times out of 200 oases).
When the tuning-fork is heard better in the occluded ear it must
not be accepted as a sign of the occlusion, as this is also observed,
as a rule, in diseases of the middle ear. If, on the other hand, the
tuning-fork is perceived through the cranial bones by the better-
hearing ear, it is very probable that there is a complication with
disease of the labyrinth. Yet in some rare cases of primary plug-
ging of the meatus with cerumen the tone is localized in the normal
ear.

Treatment, — The removal of the ceruminal plug is most surely
effected by forcibly syringing with warm water; the syringe em-
ployed should be large, capable of holding 100 to 200 grammes, and
the accumulation will be the more rapidly got rid of if the rounded
india-rubber nozzle, or the attachment with short drain, be fixed on
the syringe and pushed up to the accimiulation. Tenacious plugs
may be loosened by means of a sound.

Immediate syringing on the first examination is indicated only
when the plug has a glistening greasy appearance and feels soft on
being probed. On the other hand, when the cerumen appears
lustreless, dry, and hard, it is better to soften it by the instillation
of warm water, weak glycerine, or oil into the ear, but a solution
of soda and glycerine is best (sodsB bicarbon. 0*5, aqua dest.
glycerine pur. 55. 50 S. ten drops to be warmed and poured into
the ear 3 times daily). After twenty-four hours the cerumen is so
soft and loosened that it comes out after a few injections. When
the cerumen cannot be removed after repeated syringing it is better
to continue the instillation, because by frequent and violent in-
jections otitis externa may be excited. When the drops are pre-
scribed the patient's attention should be drawn to the fact that
the deafness wiU increase, in consequence of the swelling of the
cerumen.

After the removal of primary ceruminal accumulations the function
of hearing, as a rule, becomes immediately normal and the subjective
symptoms disappear. It is only in exceptional cases that slight
deafness remains for a few days, in consequence of the long-continued
pressure on the membrana tympani, but that quickly disappears
when the latter has attained its normal tension. After syringing, it
is necessary, as a protection from cold, and particularly in winter,
to close the ear with cotton-wool.

In the majority of cases after the removal of one mass another
accumulates. The interval between the recurrences varies from
several months to several years. There are cases, however, in
which the meatus becomes plugged with secretion in five or six

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HYPEB^MIA OF THE BXTERNAIj EAR. 167

weeks. The accumulation of secretion follows especially rapidly in
seborrhoea. In such cases the patient should be instructed in the
use of the syringe, and advised to use the drops and injections at
stated intervals.

A decrease or an entire cessation of ceruminal secretion is often observed
after the cessation of otitis externa diffusa or circumscripta, after eczema,
and especially so in the insidious adhesive processes in the middle ear
(v. Troltsch). The cause appears to lie in an affection of the trophic nerve
of the ear accompanying the disease of the tympanum. Also in recent
catarrh of the middle ear the secretion sometimes disappears, but returns
again when an improvement has been gained by treatment. Upon this
is based the assumption that the return of secretion is a favourable sign.
This is, however, contradicted by the fact that often dining treatment of
chronic adhesive processes in the middle ear the secretion returns without
any improvement in the hearing. The cermninal secretion seldom com-
pletely ceases for any length of time when the state of the external and
middle ears is otherwise normal. This anomaly is mostly found in old
people with a dry skin, and in persons who habitually wash out the auditory
meatus. Examination shows the cartilaginous section free from cerumen,
pale and dull. The want of cerumen is often accompanied by itching of
various degrees, a feeling of dryness^ and contraction in the eai*.

The treatment consists in painting the cartilaginous meatus with a small
quantity of vaseline, with unguent, prsecip. alb. (0*2 : 10), or with a mixture
of tinct. nuc. vom. and glycerine (2 : 20) occasionally.

II. Diseases op the Skin of the External Ear.

The skin covering the external ear may be the seat of a localized
skin disease, or it may form part of a general skin disease affecting
the whole body or larger portions of it. We will here describe only
those diseases which occur most frequently, and are of most importance
to the ear specialist.

A. Hypercemia of the External Ear,

Acute hypersemia of the auricle is caused either by mechanical
irritation, the action of cold (frost) or heat, or it is the expression of
an engorgement of the cutis remaining after exhausted eczema and
erysipelatous inflammation. Also the erythema exsudativ. multi-
forme, which, according to Hebra, is a true exudative process of the
skin, may be present on the auricle in all forms, from a simple
formation of spots to the development of the so-called herpes-iris-
efflorescence, but is usually part of a general erythema upon other
parts of the body. A rare form of passive hypersBmia of the auricle
occurs as a local cyanosis of angio-paralytic nature, with blueness,

Digitized by VjOOQIC

168 HYPER£MIA OF THE EXTERNAL EAB.

turgescence and coolness of the auricle, occurring in young indi-
viduals, who are usually neuropathic and hypterical, and especially
during the changes of puberty.

In isolated cases occurs a fluctuating hypersemia of the auricle, which
is to be regarded as an angio -neurosis referable to the sympathetic nerve.
Hypersemia occurs in these cases generally unilaterally, less frequently
bilaterally, and especially in the evening with great redness and warmth
of the auricle, and with a burning sensation, to which are often added
tinnitus ainium, giddiness, and slight faintings. Those quickly evanescent
conditions, returning at irregular intervals, appear sometimes in individuals
with sound ears, oftener, however, in the course of adhesive otitis media
(Burnett). For chronic hypersemia, cold compresses with Goulard's lotion,
or aqua plumbi, pencilling with tr. Busci, followed by dusting with cooling
powders (Zinc oxide. Carbon, plumbi, Amyli oryzea, da. 20'0 ; Pulv. Irid.
florentin, 2'0), and anointing the auricle in the evening with vaseline, are
recommended, and for the angio-neurotic form galvanization of the sympathetic
in the neck.

Hypersemia of the external auditory meatus regularly accompanies
hyperemia and inflammation in the tympanic cavity and in the mastoid
process. It often appears as a sequel to an exhausted inflammation of the
meatus, especially to eczemd and funmcles, and is also observed in congestion
of the head and in inflammation, near the ear, especially of the parotid.

Congestion occurs especially in the osseous, less frequently in the car-
tilaginous portion, and extends, as a rule, to the upper parts of the membrana
tympani, and along the handle of the malleiis.

Long-continued hypersemia leads to hyper-secretion of the ceruminal glands,
or to abnormal exudation with the formation of a cnunbling friable secretion.

B. Inflammations of the External Ear,
Dermatitis of the Auricle,

Dermatitis of the auricle is oftenest caused by injury, frost and.
heat, less frequently by the sting of insects. Sometimes it is
observed as an extension of erysipelatous inflammation from the
face and head.

(a) Dermatitis traumatica of the auricle occurs following many
different mechanical influences : to these belong thrusts, blows, falls
upon the ear, insect stings, cauterizing, scalding, piercing the ears for
ear-rings, and the mechanical irritation of wearing heavy ear-ringa
The intensity, duration and extent of the inflammation depends
upon the severity of the injury. The grade of the inflammation
varies between the slightest form of a transient erythematous
process to the development of circumscribed gangrene of the skin.
Severe local affections of the skin, which may extend over the cutis

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DERMATITIS OF THE AUBICLE. 169

of the whole auricle, follow very often after insect stings (bees,
wasps, horse-flies, etc.), or from the sting of muck-flies, by which
infective material is inoculated, producing the disease. The treat-
ment should be purely antiphlogistic, and be adapted to the high
grade of inflammation (applications of aqua plumbi aceti, or covering
with argilla acet. Burowi, diluted in 10 parts of ice-water).

(b) Dermatitis erysipelatosa. (Erysipelas auriculsB.) The ery-
sipelatous inflammation often starts from erosions, excoriations, and
injuries of the auricle and external meatus through infection by the
specific microbe of erysipelas (Streptococcus Erysipelatos, Fehleisen),
which finds lodgment in the portion deprived of its cutis. Oppor-
tunities for this are given by all forms of moist eczema in erosion,
maceration, and formation of fissures by the purulent secretion from
middle ear suppuration, and by any solution of the continuity of the
cutis. Primary erysipelas of the auricle is rarely seen; it occurs
more frequently with erysipelas of the face and skin of the head,
the inflammation occasionally extending to the external meatus and
the cavum tympani.

The inflammation extends over the whole auricle, and often
extends to the region surrounding the ear, the auricle appears
greatly reddened, swollen and enlarged, the skin stretched and
shining. Occasionally it forms hard, dark red nodules in the skin,
or extensive blisters (erysipelas buUosum), which flatten in a short
time and discharge a serous fluid. Rarely the affection is limited to
the lobulus.

The accompanying symptoms of the inflammation are high fever,
fulness in the head, dulling of the senses, severe burning, a feeling
of tension and pressure in the auricle, occasional twinges, followed
later by severe pain.

Cowrse. — In the lighter cases the fever and signs of inflammation
subside in a few days, and the ear returns to its normal appearance.
Even with a number of bullae on the auricle, I have seen healing
occur in a few days after the bullae collapsed, as the denuded places
are quickly covered with normal epidermis. Only rarely it goes on
to the formation of adherent crusts, after the removal of which
marked redness remains for some time.

In rare oases of severe inflammation sluggish, subacute abscesses
are formed especially on the posterior surface of the auricle, which,
if not opened at the proper time, may go on to extensive under-
mining of the skin of the auricle. Fatal results of severe migrating
erysipelas or from gangrene are very rare.

The treatment of erysipelas of the ear should be guided by the
generally known principles of antiphlogistic and antipyretic treatment.

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170

DEBMATITIB OF THE AUBICLE

(c) Phlegmonous dermatitis of the external ear is brought about
by the inoculation of pyogenic microbes (Streptococcus and Staphylo-
coccus pyogenes) in wounds of the auricular cutis. It begins gene-
rally similarly to erysipelas, with localized heat, congestion and
swelling of the skin, often with fever like a superficial dermatitis,
severe throbbing pain, increasing undefined swelling and prominence
of the auricle, together with a doughy soft fulness, extreme sensi-
tiveness of the ear, which occurs in 24-48 hours, showing often a
distinct, deep fluctuation on the third or fourth day. This manifests
the deep penetration of the inflammatory process and the sub-
cutaneous formation of pus. Incisions made as early and extensive
as possible at any portion where fluctuation is shown, with an
antiseptic bandage, will soon terminate the inflammation.

(d) Dermatitis congelationis auriculae. The skin of the auricle is
specially disposed to congelative inflammation, as its relatively thin
cuticular covering and the tightly-stretched and slight amoimt of
subcutaneous tissue to separate it from the cartilage, affords
poor protection in its exposed position. All known forms of
dermatitis congelationis are observed on the auricle. The acute
hypersthenic form, which results from excessive action of cold,
especially in the north, with accompanying freezing of the nose, and
goes on quickly to partial necrosis and gangrene of portions of skin
and the cartilage, may produce loss of part of the auricle. Then
the ordinary chronic form, with moderate swelling and redness, and
lastly, a circimiscript limited dermatitis, the true frost-bite.

These cases sometimes go on to the formation of nodules and
excoriations, especially on the elevations which show a poor
tendency to heal, and are covered sooner or later with crusts tinged
with blood. After the throwing off of these, a desquamation of the
skin often remains a long time. Youngish, chlorotic individuals,
especially girls with easily excited vascular nerves, are most generally
troubled with this affection, which occurs every year at the beginning
of cold weather. It is to be noticed that in those persons disposed
to this dermatitis, it is not due to the influence of temperature below
the freezing-point, but occm^ more frequently in low temperature
during the autumn, when it is still above the freezing-point, espe-
cially from long exposure to the air.

As subjective symptoms, it is important to notice the cutting pain
in the auricle, which is felt by exposure in the open air, especially
in dry air and severe wind, and the irritating itching, burning, and
feeling of heat, causing incessant rubbing and scratching, which
occurs when in a warm room and in bed.

Treatment, — The treatment in acute inflammation consists of the

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DEBMATITIS OF THE AUBICLE. 171

local application of cold, which must be used as long as it is well
borne by the patient. In the lighter forms, cold compresses with
Goulard's lotion and tincture of opium (200*0 : 10*0), are sufficient ;
in the severer forms, small ice-bags, or a specially formed Leiter's
apparatus, should be used. For the treatment of chronic and sub-
acute forms of dermatitis, due to cold, the washing and rubbing of
the ear two to three times a day with water as hot as can be borne,
is specially recommended. The careful pencilling of the ear twice a
day with iodine coUodium, under the control of the physician, will
relieve the unpleasant subjective symptoms. Camphor ointment is
used with good result in the form of pencilling several times a day
with the following : Camp. rassB 020, Cerea albse 100, OL lini. 150,
by which means the unpleasant itching is made better. Where the
formation of bullsB or excoriation has laid portions of the skin bare,
they should be covered with a layer of ointment (ung. cerussse,
ung. diachyli, ung. oxidi zinci, ung. argent, nitrici), to protect the
portion until the spot is covered with a new layer of epidermis.
Instead of the ointment to spread upon the ear in processes with
formation of crusts and excoriations on the skin of the auricle, the
Beierdorff-Unna's zinc and boracic ointment mull is to be preferred,
as it adapts itself to the elevations and depressions of the auricle,
and will remain many hours in position. It should be changed
morning and evening.

The occurrence of efflorescence on the auricle and in the external
meatus in the acute exanthemata should be mentioned. This is
specially so in variola in the meatus, as it often produces severe
ulcers and formation of crusts. Dusting with boric acid and the
placing of boric acid lint in the meatus produce the best result.

B. Infla/mmation of the External Auditory Meatus.

The seat of the primary forms of inflammation is the cutis of the
external meatus, from which the changes extend, but seldom to its
cartilaginous or osseous walls. It is situated either in the cartila-
ginous section, where the glandular element of the cutis is affected,
or in the osseous portion of the meatus, from which the more super-
ficial, spreading inflammation frequently extends to the cutis of the
membrana tympani. The external meatus in its whole extent is
seldom uniformly inflamed.

Otitis externa presents a series of characteristic forms, whose
character depends parbly upon the situation, partly upon the nature
of the exudation and the cause of the inflammation. As the descrip-
tion of the various clinical forms of inflammation is our aim, it must

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172 FOLLICULAB INFLAMMATION OP EXTEBNAL AUDITOBY MEATUS.

be observed that combined forms occur very often, rendering the
classification of special cases in a certain group difficult.

1. Follicular Inflammation of the External Auditory Meatus
{Otitis Externa Follicularis 8. Circumscripta).

Follicular inflammation of the external meatus has its seat chiefly
in the cartilaginous section. The process commences either in a
hair follicle or in a gland, but very often a whole group of neigh-
bouring follicles and glands is aflected. The inflammation is seated
either in the deeper parts of the cutis lying near the perichondrium
or in the superficial layers of the same.

Etiology, — Follicular inflammation, commonly called furunculosis
of the auditory meatus, occurs often without any known cause in
healthy, strong persons ; sometimes it is a part of general furuncu-
losis of the external integument. Intercurrent furuncular forma-
tions are observed in the course of chronic purulent otitis media and
chronic eczema of the external meatus. Other causative con-
ditions are : mechanical irritation of the meatus, especially frequent
syringing; scratching with hard instruments in pruritus of the
external meatus ; injuries of the same ; irritation caused by foreign
bodies; instillation of irritating substances into the ear; the pro-
longed use of alum solutions (v. Troltsch, Hagen).

Lowenberg found in fumnctdar pus not exposed to the air, masses of
micro-organisms, which he looked upon as the cause of the furoncnlosis.
The excitant of the disease has been proved to be the Staphylococcus pyogenes
aureiis and albus, which penetrate the hair follicles (Schimmelbusch). If the
pus is discharged into the meatus, multiple furuncles may arise from the
wandering of micrococci into other follicles, as is confirmed by the rapid
recurrence of furuncles in the meatus.

Occurrence, — ^Furunculosis of the auditory meatus occurs especially
in spring and autumn, so often that one is incUned to look upon the
a&ction as epidemic in character. It occurs oftener in adults than
in children ; it is often observed in ansmia, in disorders of menstru-
ation, in diabetes meUitus, and at the change of life (Hagen).

Symptoms. — The symptoms vary according as the inflammation
is situated in the neighbourhood of the perichondrium, or in the
superficial layers of the cutis. The aflection begins, particulariy
when it is deeply situated, with gradually increasing, tearing or
beating pains, which radiate towards various parts of the head and
neck, till the height of the inflammation is reached, when the
patient is robbed of his sleep. By touching the ear, but especially

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FOLUOUIaAB inflammation of EXTBBNAL AUDITOBY liEATUS. 173

by movement of the jaw, the pain is increased. The occurrence of
fever and loss of appetite are not uncommon in the first few days.
A feeling of fulness, subjective noises and disturbances of hearing
occur, as a rule, only when the lumen of the meatus becomes
blocked by a funmcle, very exceptionally when the meatus is free,
and then it is in consequence of hypersBmia spreading to the middle
and internal ear.

When the inflammation is deep-seated, the tumour due to the
exudation appears flat, without sharp outlines, and only slightly
red. When the site is superficial, on the other hand, the promi-
nence is very red, livid, and sharply-defined, and generally develops
without much pain, sometimes without any. The seat of the
inflammation is most frequently the anterior inferior wall of the
meatus. Often the furuncles are multiple, arising simultaneously
or rapidly succeeding each other, so that by mutual contact they
close up the lumen of the meatus. When they form on the anterior
wall of the auditory meatus, the region in front of the tragus appears
swollen and of a bluish-red colour, and when they are seated on the
posterior wall there is sometimes so much swelling over the mastoid
process that it might be mistaken for periostitis mastoidea. I once
saw a fluctuating abscess on the mastoid process following a furuncle
of the meatus, which emptied upon incising the furuncle in the
meatus, and after applying a pressure bandage healed in a few days.
Coincident glandular swellings on the side of the neck are on the
whole rare. Follicular abscesses in the inner portion of the cartila-
ginous, and at the beginning of the bony meatus, appear mostly as
yellowish-green pustules, about the size of hemp or millet seed, on
the posterior and superior wall of the meatus.

Course. — ^The exudation thrown out in the neighbourhood of the
follicle in most cases after the inflammation has lasted for four or
five days, breaks down into pus. It is seldom that the abscess does
not form before eight or ten days. Bursting usually takes place at
the yellowish acuminate prominence at the highest part of the
tumour, rarely at the side. The deeper the seat of the exudation,
the more delay is there in the discharge of the abscess into the
meatus. The inflammation seldom subsides without the formation
of an abscess.

After the spontaneous or artificial opening of the abscess, the
violent pain, as a rule, disappears, and gradually also all the other
symptoms. Sometimes, however, violent exacerbations occur, in
consequence either of recurrences at other parts, or of plugging of
the opening of the abscess and obstruction to the escape of the pus
from its cavity.

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174 FOLLICULAB INFLAMMATION OP EXTERNAL AUDITORY MEATUS.

After the abscess has discharged, the tumour subsides in a short
time ; yet there often remains a slight infiltration and elevation on
the affected part for some weeks. Spongy granulation tissue often
projects from the orifice of the abscess- cavity, and may be mistaken
for a fungiform polypus on the wall of the meatus. The course is
always protracted by such growths, and cure is efTected only after
they have been removed.

Furunculosis of the auditory meatus tends to relapse. They
appear either spontaneously or following repeated mechanical
irritation, sometimes at shorter, sometimes at longer intervals
(habitual furunculosis), and often cause emaciation and nervous
excitement.

Diagnosis, — Having regard to the subjective and objective
symptoms, this presents no difficulties. On a superficial examina-
tion exostoses in the external meatus, covered with reddened cutis,
and those bulgings of the wall of the meatus which develop in the
course of inflammation of the mastoid process, might be confounded
with furuncles. The formation, sometimes with great pain, of single
or multiple pustules in those parts of the osseous section of the
auditory meatus in which the glandular elements are wanting, does
not belong to the category of follicular inflammations.

Treatment. — In the stage of exudation the chief end of treatment
is to allay the pain and get rid of it as soon as possible. In very
painful, deep-seated inflammations it is best to make an incision in
the tumour with or without local anassthesia ("Ldwenberg), whether
suppuration has commenced or not. In the latter case a bloody
liquid wiU be discharged through the incision, and the pain will be
alleviated by the relaxation of the cutis. When the pus is not
reached by the incision it very soon makes a way for itself into the
opening. The incision, which is performed with a small, blunt
bistoury, is also recommended when the pus has reached the
surface of the cutis, and the tumour is pointing at one place, but
has not burst on account of the resistance of the dermic layer.
Even in those cases in which an opening has already formed on the
surface, which, on account of its smallness or in consequence of
being plugged by a furuncle, is insufficient for the discharge of the
pus, it is often necessary to extend the opening. After spontaneous
or operative opening of the abscess it is advisable to exert moderate
pressure on the external surface of the cartilaginous meatus, in order
to bring the pus and the furuncular plug from the deeper parts to
the surface.

Besides incision, other remedies may be used to allay pain ;
narcotic embrocations round the ear {v. Treatment of Acute Middle

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TREATMENT. 175

Ear, Inf.) ; little plugs of wadding dipped in a mixture of aq. opii 40,
aq. dest. 120, or a 5 per cent, solution of cocaine, and put into the
auditory meatus ; the introduction of a longish piece of lard covered
with morphia and boracic ointment (boracic acid 1-0, vaseline 20-0,
acet. morph. 0*2) into the auditory meatus ; and the application of
a warm raisin boiled in milk (popular remedy). These remedies are
particularly recommended in the case of those who are afraid of
operations. Leeches are rarely used ; they are only necessary when
incision does not allay the pain. Warm poultices allay the pain in
some cases, while they increase it in others. On the other hand, I
have recently seen rapid relief follow the application of Leiter's
cooling apparatus {v. Treatment of Inflammation of the Mastoid
Process). According to Eohrer, in many cases carefully carried out
hydropathic fomentations produce rapid easing. Syringing the ear
is to be avoided, as it may give rise to fresh eruptions.

The introduction of antiseptic treatment has made considerable
improvement in the therapeutics of funmculosis of the external
meatus. While with the earher methods of treatment multiple
furuncles were more frequent, and there were no known remedies
for the prevention of fresh eruptions, it was observed that with
antiseptic treatment new eruptions and relapses were less frequent.
The most effectual remedies are carbolic acid as carbolic glycerine
(0*5 in 150) apphed with a brush, or dropped on cotton and placed
in the meatus, boracic acid as a powder (Morpurgo) or as an alcoholic
solution in the proportions of 1 in 20 (Lowenberg), further, the
argilla acet. Burowi and the aluminium acetico-tartaricum (Hart-
mann), as instillation or by soaking cotton in the solution and
applying in the meatus. All these remedies may be used before and
after the opening of the abscess. I have seen the furuncles, after
repeated painting with carbol-glycerine, recede without bursting into
the meatus. When they recur repeatedly, one can use the stronger
antiseptic solutions by instilling sublimate alcohol (Hyd. bichlor.
0*05 — 01, Spirit, vin. rectf. 50*0, Kirschner). This method is pre-
ferable to that proposed by Wilde, of cauterizing with silver nitrate,
and that of Weber-Liel and Bendelak-Hewetson, to inject 2-5 drops
of a 5 per cent, carbolic solution into the furuncle, which is very
painful. Novarro (Milan, Congressber., 1880) has seen good results
from cauterizing with the subchloride of zinc.

After the furuncle has been cut, the incision should be immedi-
ately anointed with carbolic glycerine or solution of boracic acid, to
act on the micrococci and to prevent the bacteria from wandering
into the neighbouring follicles ; and it is advisable to continue the
instillation of the argilla acet., subhmate, or boracic solution till the

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176 FOLLICULAB INFLAMMATION OF EXTERNAL AUDITOBY MEATUS.

incision is cicatrized. Cholewa and Szenes recommend the intro-
duction of menthol ; Eohrer the instillation of hydrogen peroxide.
In chronic furunculosis of the meatus, Schwartz uses lukewarm
ear-baths with a 1 per cent, solution of potassium sulpL when the
inflammation has subsided.

After 'Treatment, — After the follicular inflammation has terminated,
the cenuninal secretion either ceases altogether or is of a crumbling,
scaly nature. This abnormal secretion is usually accompanied with
a troublesome itching, which causes the patient to scratch the
meatus with all sorts of hard bodies. Such mechanical irritation is
frequently the cause of relapses. The patient must therefore be
strictly forbidden to scratch the meatus.

To prevent this ti'oublesome itching, it is recommended that the
cartilaginous meatus should be anointed every second day for
several weeks after the disappearance of the furuncle with a precipi-
tate ointment (hydr. praecip. alb. 0-3, ungu. emoll. or vaseline 12-0),
or with boracic ointment (1 to 20 vaseline or lanoline), to which a
little oleate of cocaine (5 per cent, of the basis) is added. The
ointment must be sparingly applied, as by the introduction of large
quantities the meatus would become blocked up in a very short
time. I have also found painting with alcohol, as recommended
by Weber-Liel, useful in several cases. Frequent wetting of the
meatus vnth water, as in washing, is quite as injurious as in the case
of eczema.

2. Diffuse Inflarrvmation of the External Auditory Meatus
{Otitis Externa Diffusa),

Diffuse inflammation of the external auditory meatus is very rare
as an idiopathic aflection, and the pathogenic microbes which And
their way into the meatus from externally take an important part.
It is more frequently due to the instillation or injection of irritating
substances, or to mechanical and traumatic causes. Hessler
{A,f, 0., vol xxvi) observed after injuries, infectious inflammation
of a phlegmonus character. I cannot confirm the assertion that
this affection occurs most frequently in children. I have repeatedly
convinced myself that this diagnosis is often made in children in
cases of acute purulent otitis media, the mistake arising from the
fact that examination with the speculum is impossible; although
this form often shows a desquamative character, the occurrence of a
pustular inflammation of the external meatus is VTithout doubt.

Symptoms. —The symptoms of otitis externa are specially marked
in the osseous section and on the external surface of the membrana

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DIFFUSE INFLAMMATION OF THE EXTERNAL AUDITORY MEATUS. 177

tympani. The inflammation begins with great hyperseraia and
painful swelling of the cutis, followed in a few days by a serous or
viscid exudation. More than once I have observed the formation of
a solid, transparent, gelatinous plug of exudate, especially during
the influenza epidemic. On examination the contracted meatus
and the external surface of the membrana tympani are found covered
with a white layer of epidermis, which on syringing peels off,
retaining the pouch-like form of the canal. In several cases upon
microscopical examination I found such plates of epidermis containing
large numbers of micrococci, which speaks for the mycotic nature of
the affection. After the removal of this pouch the cutis and mem-
brana tympani appear red and swollen, parts of the malleus are
not visible, and the boundary between the membrana tympani and
the auditory meatus is obliterated. Sometimes the meatus is so
contracted by difiFuse swelling or simultaneous foUicular inflamma-
tion in its cartilaginous section that it is impossible to get a view of
the deeper parts.

The subjective symptoms of otitis externa are violent radiating
pains, increased by pressure near the ear and by the movements of
the jaw ; sometimes there are also subjective noises and giddiness.

The function of hearing is normal or but slightly impaired. It
is only when the cutis of the membrana tympani is greatly swollen,
or when there is an accumulation of exudation and epidermic plates
in front of the membrane, and in cases of secondary swellings in the
middle ear, that there is great difficulty of hearing.

In some cases I observed a group of s;>'mptom8 deviating from those
described ; the inflammation developed with very slight reactive phenomena,
bat with rapidly increasing deafness and tinnitus. On examination, the
meatus was found filled with an epidermic plug reaching to the membrane ;
after its removal the noises and deafness disappeared. The lining membrane
of the meatus and the membrana tympani were moderately swollen and
reddened, and covered with a thin layer of pus. Examination of the plug
with the microscope revealed masses of micrococci in and on the cells.
Whether these are the cause of the disease in such cases or are developed
after exudation, has not yet been ascertained.

Course and Besult, — In some cases the acme of the disease is
reached on the third day, in others the course is irregular, the
symptoms of resolution being followed by repeated exacerbations,
with increased exudation and desquamation of epidermic plates.
Therefore a cessation of the inflammatory phenomena can be looked
upon as a sign of resolution only when the secretion ceases and the
meatus becomes dry.

The result of this form of inflammation is generally recovery, with

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178 DIFFUSE INFLAMMATION OF THE EXTERNAL AUDITORY MEATUS.

complete restoration of the function of hearing; but subjective
noises and deafness may remain long after the cessation of the
inflammation of the meatus. The acute form sometimes, though
not often, terminates in circumscribed ulceration on the membrana
tympani, with perforation from without inwards, or in circumscribed
ulceration on the inferior wall of the osseous meatus, with exposure
of the bone and the growth of granulations in the area of the ex-
posed parts. I observed once after the removal of a granulation
which had arisen after four weeks' duration of the inflammation,
the formation of an ulcer on the posterior superior wall of the meatus,
which extended to the posterior half of the membrana tympani, and
only healed up after being touched several times with powdered alum.

Transition into the chronic form is rare. It subsides generally
without pain, often with great itching, and sometimes with sub-
jective noises and deafness. The secretion is seldom so abundant
that it runs out of the ear ; it is usually of a thick, offensive, greasy
nature, and contains, besides epidermis and pus-cells, many micro-
cocci. After cleansing the meatus, the osseous section is found
swollen, and often on its posterior superior wall, and sometimes on
the dull membrana tympani, one or more granulations of the size of
a hemp-seed are seen. Through apposition and adhesions such
growths may form bands of tissue in the meatus (Engelmann, Bing).
Sometimes in chronic inflammation of the osseous section a fibrous
polypus, filling up the meatus, is developed, after the removal of
which the membrana tympani appears intact. As a rule, one or
two days after the extraction of such polypi, the secretion stops
completely, and the hearing at the same time becomes quite normal.
Occasionally a chronic desquamation of the ear remains.

Termination of the inflammation in hypertrophy of the cutis, in
periostitis, and in hyperostosis with contraction of the meatus, in
ulceration and extension of the suppuration to the parotid, and in
caries, necrosis, and exfoliation of the flatter plates of bone in the
wall of the meatus, without or with rupture towards the mastoid
process, the cranial cavity, the sinus mastoideus, and the maxillary
joint, is seldom met with in idiopathic, but chiefly in the traumatic,
and in those secondary inflammations of the meatus arising in the
course of chronic otitis media.

Diagnosis. — The diagnosis of primary otitis externa can only be
made with certainty when the view of the walls of the meatus and
of the membrana tympani is uninterrupted on every side, and when
there is no suppuration in the middle ear. The diagnosis is more
difficult when the meatus is much contracted, and when there is
simultaneous follicular inflammation, as those conditions are very

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PROGNOSIS. — TREATMENT. 179

often (^mbined with diffuse swelling of the walls of the meatus.
To complete the diagnosis the epidermic scales which have been
cast off must be microscopically examined for micrococci and
aspergillus fongas.

Prognosis, — The prognosis of idiopathic otitis externa is favour-
able, as not only do the acute forms subside without after-effects,
but even those chronic cases in which granulations or large polypi
have developed recover after their removal. Less favourable is the
prognosis of traumatic inflammation and of those caused by corrosion
of the walls of the meatus, which may produce stricture and atresia
of the meatus, or with carious ulceration of the osseous walls, as the
inflammation may spread to the cranial cavity or to the lateral sinus
(Toynbee).

Treatment, — In acute inflammation, so long a» the violent reactive
symptoms last, the same palliative treatment is suitable as in acute
otitis media. In the idiopathic form antiphlogistics (cold, local
bleeding before the ear) are only to be used in the severer forms ;
in traumatic inflammations, on the other hand, cold applications,
especially Leiter's apparatus, are recommended. With the com-
mencement of secretion and shedding of the epidermic scales, local
antiseptic treatment must begin. In acute cases it is almost always
sufficient, after washing out the ear with a 2-3 per cent, solution of
carbolic acid or with a weak solution of Lysol (2 per cent.),
to insufflate finely-powdered boric acid, to stop the secretion. In
chronic cases, where the swelling is not severe and no formation of
granulations in the meatus, boric acid may be tried first. If the
effect is not good after a few days, it is better to wash out the
meatus with antiseptic solution, and instil boracic alcohol (1 in 20),
boracic glycerine (Cresswell, Baber), sublimate alcohol (0*05 in 50),
or iodol-alcohol (1 in 20). In obstinate cases this method first proves
effectual after several cauterizations with a concentrated solution of
nitrate of silver (0*8 in 10 0). After using the medicine the ear should
be stopped every time with carbolized cotton. Where ulcers exist,
which, in spite of the antiseptic treatment, show no tendency to
heal, they should be cauterized several times after anaesthetizing
with powdered cocaine.*

There remains yet to describe that desquamative inflammation of the
external meatus, which is generally chronic in its course and goes on to the
formation of cholesteatomous masses in the meatus. To this belong the
* molluscous ' timiours of Toynbee and the * keratosis obturans * of Wreden
{A./. A, u. 0,, vol. iii.). These cholesteatomas of the external meatus are

* For thoM inflammations of the auditory meatus complicated with the formatioii
of granulations and polypi, see the section on Aural Polypi.

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180 OTITIS EXTERNA HAMOBBHAQICA.

rarely the product of an acute otitis externa with exuberant desquamation, but
more often follow a chronic desquamative process frequently without symptoms,
which, as I have many times seen, may go on to atrophy of the cutis and
absorption of the bony wall's. In the post-mortem room I have seen and
dissected a number of cases, mostly both-sided, in which the meatus in its
whole extent to the membrana tympani, was filled with a whitish lustrous
cholesteatoma, without any change in the cavum tympani. In the majority of
the preparations the lumen of the meatus was much enlarged, and either the
superior posterior wall was hollowed out or the anterior wall was thinned,
broken through, and the ossification openings which were present increased
in size. In two preparations the posterior wall of the meatus was abraded
so as to form an opening into the mastoid cells. By carefully removing the
cholesteatoma through thorough syringing of the ear, and instilling boracic
alcohol (1 in 20), the return of the epidermal mass may be prevented.

3, Otitis Externa Hamorrhagica.

This form is characterized by hsemorrhagic effusion in the osseous
portion of the external auditory meatus, seldom in the cartilaginous
portion, accompanied with more or less well-marked reactive
symptoms (Bing). It occurs usually in yoxmg persons without any
knovm cause — frequently seen with influenza — commencing with
moderate pain, tinnitus, and slight deafness. Examination reveals
one or more dark blue elongated swellings in the osseous meatus,
situated on its inferior, more rarely on its posterior walls ; these
often extend to the inferior posterior segment of the membrana
tympani on the one side, and on the other to the cartilaginous
meatus, and by contracting the lumen of the meatus they interfere
with the examination of the membrane. The condition in such
cases is one of superficial inflammation of the cutis, the epidermis
being raised to a great extent by the haemorrhagic exudation. On
being probed, the swelling feels soft and yielding, and may be
perforated by very slight pressure, a blood-coloured fluid escaping.
Schwartze has observed the formation of hsemorrhagic vesicles in
the osseous meatus at the beginning of violent otitis media. In one
case of Wagenhauset's there was delirimn with hallucinations
{A,f, 0., vol. xxi.). ■

The acme of this form of inflammation is, as a rule, reached on
the third day. The hsemorrhagic vesicles may remain for several
days after the disappearance of the reactive symptoms, their con-
tents being discharged by rupture or absorbed. Very often after
the disappearance of the vesicles, others appear on different parts of
the meatus. This disease can only be confounded vvrith the
hsemorrhagic bullaB which. are produced by rarefying the air in the
external meatus (Rohrer), or with livid-coloured polypi.

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OTITIS EXTERNA CR0UP08A ET DIPHTHBBITICA. 181

The result of otitis externa hsBmorrhagica is always recovery ; the
elevated epidermis of the meatus and of the membrane being cast
off in large scales after eight to fourteen days, the diseased parts
become covered with a delicate dry epidermic layer, and the hearing
becomes normal.

Treatment consists in opening the vesicles by means of a probe,
and the subsequent removal of their contents by the insertion of
Bruns* cotton into the meatus. The latter is then filled with
powdered boracic acid, and this application is repeated till the
powder remains perfectly dry for twenty-four hours. As a rule the
powder only requires to be used three or four times to check the
secretion in the meatus and on the external surface of the membrana
tympani.

4. Croupous and Diphtheritic Inflammation of the External Auditory
Meatus {Otitis Externa Grouposa et Diphtheritica),

Croupous otitis externa is one of the rare forms of disease of the
external meatus. Wilde (I. c, pp. 231, 232) indicates its occurrence,
for he sometimes found the meatus and the membrana tympani
covered with a layer of lymph, similar to that which lines the
trachea in croup. Gottstein observed in one case, along with a
croupous exudation on the tonsils, a croupous membrane adhering
to the posterior wall of the osseous portion of the meatus, after the
removal of which the excoriated surface bled slightly. Attention
was first drawn to this form of disease by Bezold's communications
(Virch. Arch,, vol. Ixx.). He saw eleven cases of this affection in the
space of three years. These are included in the thirty cases reported
by Steinhof (Inaugural dissertation, 1886). The exudation of fibrin
is confined to the osseous section of the meatus and the external
surface of the membrana tympani. It seldom occurs alone, but
usually after an exhausted otitis media, or along with furunculosis
of the meatus. The formation of fibrinous membranes takes place
at intervals of from one to two days ; they may be loosened from
the underlying tissue by moderately strong injections, and appear
as solid, firm casts of the osseous meatus and of the membrana
tympani. According to Steinbriigge, the exudate consists of a fine
network, which is filled with round cells, nuclei and epithelium.
Guranowski {M.f. 0., 1888) isolated the bacillus of green pus from
the membranes of the patient described by him.

This inflammation, which usually affects healthy people, is deve-
loped with moderate pain, which reaches its acme with the com-
mencement of fibrinous exudation, and ends, as a rule, with the

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182 OTITIS EXTEBNA CB0UP08A BT DIPHTHERITICA.

casting off of the membrana The exudation may be repeated
several times, but ahnost always without any other complication ;
it ends in recovery with complete restoration of the hearing.

The prognosis of this form of inflammation is very favourable.

Treatment consists in the removal of the croupous membrane by
means of injections, or with the forceps, and the subsequent insertion
of boracic acid into the meatus.

Otitis externa diphtheritica, occasionally combined with diphtheria
of the auricle, seldom appears primarily, but is usually a complication
of scarlatinous diphtheria of the throat and of the middle ear.
Primary diphtheria of the meatus is, according to the observations
of Moos, Bezold, Wreden, and Kraussold, developed during an
epidemic diphtheritis out of an already existing otitis externa on
excoriated parts of the meatus.

In the primary as well as in the secondary forms of this affection,
the walls of the meatus appear covered with a dirty grayish-white
exudation, which cannot be removed either by injections or by the
forceps. After the membrane has been forcibly loosened by the
probe, the wall of the meatus appears excoriated, ulcerated, and
bleeding. The slightest touch on the idcerated parts is extremely
painful The meatus is sometimes so contracted that it is possible
to get a view of the deeper parts only after necrosis and shedding of
the membrane (Blau). The parts about the ear are red and swollen,
as are also the lateral cervical and the lymphatic glands behind the
ear. Inflammation, commencing with moderate secretion, is accom-
panied in the primary form with great pain, feeling of fulness,
tinnitus, and deafness; that, on the other hand, associated with
diphtheria of the middle ear runs its course, according to Wreden,
Wendt, and Blau, almost without pain, and with anaesthesia of the
region of the ear.

Diphtheritic inflammation of the meatus has an imcertain course.
Sometimes the exudation is rapidly thrown off, but often it remains
firm for a very long time, or there are repeated exudations either on
the already affected or on other parts of the meatus. In a very
interesting case of diphtheritis of the middle ear and of the meatus
described by Blau, the affection extended to the auricle, on which
deep cutaneous ulcers were formed.

Diphtheritic inflammation of the meatus terminates without any
permanent changes when the seat of the exudation is superficial ;
on the other hand, when the affection is deep-seated, the ulcers on
the cutis, persistent and easily made to bleed, heal by cicatrization,
narrowing and adhesion of the meatus.

The diagnosis of diphtheria of the meatus can be made with

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OTITIS EXTEBNA CR0UP08A ET DIPHTHERITICA. 183

certainty only when the presence of the peculiar adherent diph-
theritic membrane has been ascertained by examination, after the
removal of which an ulcerated bleeding surface is exposed. The
diagnosis is rendered more probable when there exists an epidemic
of diphtheritis, and coincident suppuration of the middle ear, along
with naso-pharjmgeal diphtheritis. The white exudations seen in
children, occurring in the course of acute scarlatinous suppuration
of the middle ear, extending to the external orifice of the ear, and
due to maceration of the epidermis, must not be confounded with
diphtheritis of the meatus. They differ from the latter in being
easily peeled off in large flakes.

The prognosis of primary diphtheria confined to the meatus is, on
the whole, favourable. The prognosis of the forms complicated with
pharyngeal and middle ear diphtheritis is unfavourable ; for, on
account of the simultaneous extensive destruction of the membrana
tympani, the frequent exfoliation of the ossicles, the consecutive
caries, and very often the addition of an affection of the labyrinth,
the function of hearing is much impaired.

The treatment of otitis diphtheritica is antiseptic. In primary
diphtheritis of the meatus it is advisable, according to Burckhardt-
Merian, to fill the canal at times with lime-water, in order to favour
the loosening and separation of the diphtheritic membrane. After
the fluid has been left for fifteen or twenty minutes in the ear the
meatus should be syringed with a weak solution of boracic acid,
and then filled with finely-powdered boracic acid or iodoform powder.
If the membrane is repeatedly formed again, the affected part
should be touched with carbolic glycerine (1 in 15) or carbolic spirit
(1 in 20), and in addition the meatus should be filled several times a
day with an alcoholic solution of boracic acid (1 in 20), or with one
per cent salicyl. -alcohol or with sublimate alcohol (0*05 in 50*0).
Mechanical removal of the diphtheritic membrane hastens the
recovery just as little as cauterization with lunar caustic.

6. Parasitic Inflammation of the External Auditory Meatus — Mycoses

of the External Meatus

{Otomycosis \yirchow\ Myringomycosis Aspergillina [Wreden]),

Although single cases of fungus in the ear had already been observed by
Mayer,* Pacini,t and Carl Cramer, J the attention of otologists was first drawn
to parasitic otitis externa by a short communication of Schwartze*s (A.f, 0.,ii.),

• MUller's Arch./. Anat,, etc., 1844.

t Firenze, 1851.

X Viertdjahrschr. d. ncUurf. Oes. in Zurich, 1859-60.

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184 PARASITIC INFLAMMATION OF EXTERNAL AUDITORY MEATUS.

and particularly by a detailed work of Wreden's (Monograph, 1868). More
recently the pathology of otomycosis has been greatly enriched by valuable
contributions from Burnett, Blake, Cassells, Hassenstein, Hagen, Bezold,
Steudener, Liiwenberg, Wagenhauser and Siebenmann.

The most common fungus in the ear belongs to the species Asper-
gillus niger, flavus and fumigatus. The following are much rarer : the
VesticDlium Graphii (Trichothecium roseum), described by Steudener ; a
fungus with grass-green conidia (Otomyces Hageni), described by Hagen;
the Aspergillus nidulans; and the Ascophora elegans of v. Troltsch. The
Mucor corymbifer (Lichtheim's), iirst observed in the meatus by Wagen-
hauser; the Eurotinus malignum of Lindt and Siebenmann, the Mucor
sextatus and Penicillima minimum.

An examination of a fungous mass removed from the ear gives the follow-
ing result : there is a felt-like, myceUal structure, intermixed with cast-off

Fig. 84.— Aspergillus Nigricans.

a, Mycelium covered with numerous fallen spores ; 6, Hypba ; c, Sporangium, with

ripe spores ; h\ Hypha ; d, Receptaculum ; e^ Sterigmata with spores.

epidermis, from which arise upright, cylindrical, rigid filaments, often
furnished with septa (Hyphse, Fig. 84, 6, 6'), which support the head of the
fungus (sporangium or fruit-capsule, c). The latter consists of the central
vesicular enlargement (receptaculum, rf), the long radiating cells seated upon
the latter (sterigmata, e), and the round conidia or spores growing on its free
end.

The colour of the various forms of fungi depends upon that of the conidia.
They are blackish-brown in A. nigricans, yellowish or greenish in A. flavescens
and in A. glaucus, and grayish-black in A. fumigatus. According to Burnett
(Am, Journ, of Ot, 1879), the fructification-heads are smaller and narrower
in A. glaucus than in A. nigricans. A. fumigatus possesses the smallest
sporangium, and, accordmg to Bezold, more rarely occasions inflammation
in the ear than the other species. The Mucor corymbifer is distinguished
by the clustered position of the sporangium bearers, the small colourless
pear-shaped heads, the brownish twisted columellffi and the small colourless
spores.

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ETIOLOGY. — SYMPTOMS. 185

Etiology. — The fungous spores which reach the meatus from the
atmosphere can, under favourable circumstances, germinate and
increase very rapidly. According to Siebenmann, an abnormality
of the secretions in the meatus (Eczema squam. and slight secretions
in Otit. med. sup. chron.) forms the principal condition for the
growth of the aspergillus in the ear. If the conditions for germina-
tion of the fungus are present, it can occur in the meatus easier, as
it is here protected from all mechanical effect. According to Bezold,
fungous growths are oftenest observed after the instillation of oily
substances, which, like all fats (Lowenberg), form a very nutritive
material for the development of fungi. Fungi are often developed in
the ears of persons living in a damp, mouldy locality. One case of
mine was observed in a young man employed in the manufacture
of yeast. Very often the cause of otomycosis cannot be ascertained.

Occurrence, — Otomycosis running its course with reactive pheno-
mena occurs usually in middle-aged people, and rarely in children
and in old people ; it is more common among the poor than
among the rich. The frequent development of fungi in individuals
affected with chronic catarrh of the middle ear, depends certainly
upon the instillation of easily decomposing substances into the
auditory meatus. In chronic suppuration of the middle ear fungous
growths are often developed on moist scabs, especially during the
use of chloride of iron, but without causing any inflammatory
phenomena. Burnett and Bezold have observed the fimgus extend
into the tympanic cavity. In one of the preparations in my collec-
tions the mycelium can be seen penetrating the membrana tympani.
Fungous growths have not been observed in cases of profuse sup-
puration of the middle ear.

Symptoms. — Fungous growths in the auditory meatus, even when
extending over a great part of it and of the tympanic cavity, may
exist without any symptoms, so long as the fungus has its seat in
the epidermis. When, however, the vegetations penetrate into the
rete Malpighii and come in contact with the living tissue, that
pecuUar form of inflammation known as otitis externa parasitica
commences. In two cases of aspergillus without symptoms observed
by me, after a shght abrasion of the meatus a severe mycotic in-
flammation occurred. According to Wreden, the inoculation ex-
periments which he made in healthy meatuses remained without
results.

The subjective phenomena of parasitic otitis externa are great
itching and flying twinges, which increase to violent pains radiating
towards the head and throat. In most cases tinnitus and deafness
are superadded.

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186 PARASITIC INFIiAMMATION OP EXTERNAL AUDITORY MEATUS.

On examination of the meatus in cases of A. nigricans, the
osseous section especially and the membrana tympani are found
covered with a black-spotted or entirely black membrane having
the appearance of being strewn with fine coal-dust. On syringing
it is washed out in shreds of considerable thickness, on the surface
of which the characteristic black spots (sporangia) are visible either
with the naked eye or with a lens. The side of the membrane
lying next to the wall of the meatus is of a whitish or dirty gray
colour. According to Lowenberg, the epidermis permeated with
mycelium may take the form of small cysts, on the inner surface
of which the fungous growths are seated. In cases of A. flavesc,
the surface of the epidermis invaded with mycelium appears covered
with a yellowish mass of dust like the powder of lycopodium.

After removal of such membranes from the meatus, the lining
membrane of its osseous section and the membrana tympani jgre
found very red, swollen, and in great part devoid of the epidermic
layer. Here and there, however, are seen solitary, irregular gray
islands, on which after removal with the probe epidermic cells
mixed with fungous spores are recognised. In a growth of the
fungus without inflammation of the walls of the meatus one can
see the black or yellowish clump of fungus spreading out over a
portion of the osseous meatus, and the hyphsB and sporangii may
be seen with the naked eye or by slight magnification.

Course and Termination, — The Qourse of parasitic otitis externa
depends upon the extent of the fungous growths and the time
treatment commenced. When the affection is left to itself or
treated by a physician who does not know its nature, the inflam-
mation may continue for several weeks without in the least abating,
and, as I have observed in several cases, may lead to perforation
of the membrana tympani from without inwards. In many cases
the inflammation ceases, notwithstanding the presence of fungous
growths in the ear, only to reappear with renewed vigour at
intervals of weeks or months. On examining such cases the
meatus is very often found filled with fungous membranes closely
packed.

Immediately after removal of the membrane in the inflammatory
stage there is a decided diminution of the pain and of the sub-
jective noises, speedily followed by cure on proper treatment being
employed. When, however, aftef the removal of the fungous
membrane no antiparasitic remedy is used, on the following
day, the meatus is often found re-covered with a thick fungous
membrane similar to what had been already removed, with continu-
ance of the reactive symptoms. Such rapid recurrence may go

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DIAGNOSIS. — PBOOMOSIS. — TREATMENT. 187

on till either the fungus becomes exhausted or treatment effects a
cure.

Diagnosis, — The diagnosis of fungous growths in the meatus pre-
sents no diflSculty when with decided symptoms of otitis externa
the characteristic appearance of the meatus is found on examina-
tion with the speculum. Sometimes, however, blackish-brown
epidermic plates are syringed out of the ear, on which the brown
covering appears as dust, coal-dust, or vegetable debris, which might
be mistaken for those fungous membranes. In doubtful cases,
therefore, microscopic examination is indispensable before giving a
diagnosis.

Prognosis, — The prognosis of otitis externa parasitica is in all
respects favourable, as, by the use of parasiticides, a rapid cure
is effected, and, even after perforation of the membrana tympani,
cicatrization of the aperture speedily follows. The prognosis is not
so favourable, however, when there is the possibility of a recurrence
of the inflammation, particularly in persons who live in damp,
mouldy localities, in which the cause of a renewed attack is always
present. I have also seen frequent relapses in persons in the most
favourable circumstances without apparent cause.

Treatment — Of the numerous remedies recommended for the
removal of fungous growths, rectified spirit, recommended by
Hassenstein and Kiichenmeister, has proved the best. It is used
as follows: After the fungous membranes have been nearly all
removed by syringing, the meatus is then filled by means of a
warm spoon with rectified spirit, which is kept in the ear for at
least a quarter of an hour. This procedure is, at first, to be repeated
twice daily. As a rule, the spirit can be well borne. When it
causes a burning feeling, it is advisable at first to dilute the spirit
with distilled water, and gradually to employ concentrated spirit of
wine. In protracted cases I have seen a rapid result from instilla-
tion of an alcoholic solution of sublimate (005-0'l in 500).

The result of the treatment is so quick, that even after two days
no sign of fimgus is visible in the meatus. The lining membrane
of the meatus and the membrana tympani appear covered with a
fine dry epidermis; pain, tinnitus, and deafness disappear, and
after three or four days' treatment the cure is almost complete.

In order to prevent relapses, I consider it well to advise the
patient to continue the application of the spirit at longer
intervals, but at least once every four weeks, throughout a whole
year.

Besides alcohol, there are a number of other remedies for the
destruction of fungL Among the most effective of these are boracic

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188 PAKA8ITIC INFLAMMATION OF EXTERNAL AUDITORY MEATUS.

acid in powder or in spirituons solution (1 in 20), or mixed with
an equal amount of oxide of zinc (Theobald) ; permanganate of
potassium in 6-10 per cent, solution (v. Troltsch, Schwartze, Hagen) ;
carbolic acid free from creosote (30 in 1000 oil or glycerine, Lucae) ;
spirituous solution of tannin (50 per cent, Wreden) ; spirituous
solution of salicylic acid (2 per cent., Bezold); chlorinated lime
(007-015 in 35*0 aq. dest., Wreden) ; hyposulphite of soda (0*2 in
300, Blake, Burnett) ; and pyoktanin powder (Eohrer).

Pityriasis alba, described by Ladreit de Lacharri^re {AnnaL des
Mai de VOreilles, etc., 1875), remains to be mentioned as a rare
mycosis. It occurs along with pityriasis capitas at the age of from
forty to fifty years. After removal of the scales, which microscopic-
ally show the characteristic fungous spores, the cutis of the meatus
appears thickened and red. This mycosis is not to be confounded
with seborrhoea of the meatus, in which there is also a formation of
fatty scales. The treatment of P. alba consists in the extraction of
the stiffest hairs, and in painting the lining membrane of the meatus
with a 1 per cent, solution of corrosive sublimate.

Kirchner observed a transplantation of pityriasis versicolor from
the breast and neck to the external meatus, where it produced a
troublesome itching but no other disturbance. Lang saw the
dermatomycosis favosa and circinata on the auricle. The first
cannot well be mistaken ; the latter, not alone, but combined with
a similar affection of the neck, may be mistaken for an annular
syphilide.

C. Eczema of the External Ear,

Eczema of the external ear occurs either as a primary affection or
combined with eczema on other parts of the body. It is either acute
or chronic.

Acute eczema attacks either the auricle or the external meatus, or
extends over the whole of the external portion of the ear. It begins
with great redness and swelling of the skin, which is soon followed
by the formation of numerous thickly spread vesicles containing
serous matter (Eczema vesiculosum). The eruption mostly occurs
on the posterior surface of the auricle and on the lobule, the entire
auricle seldom being affected. Vesicles are rarely visible in the
auditory meatus on account of their early destruction.

After the bursting of the vesicles moist surfaces, denuded of epi-
dermis, are found on the auricle and in the meatus, which become
covered in a few days with light yeUow crusts (Eczema crustosum),
under which the exudation of a serous or viscid fluid continues.

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ECZEMA OF THE EXTERNAL EAR. 189

Occasionally, when there is very severe inflammation, pustules filled
with pus occur about the size of a bean, which form thick crusts on
bursting, under which the pustular secretion still remains (Eczema
impetiginosum). The serous secretion contains diplococci according
to Rohrer, and the later pustular accumulations contain staphylococci
and baciUi.

Etiology, — Acute eczema is developed primarily or combined with
eczema of the face, either without any known cause, or in conse-
quence of external sources of irritation, especially after cold baths,
from the influence of heat (Eczema solare), warm fomentations, or
the application of irritating drugs (chloroform, rancid fat and oils,
mercurial ointments, mustard-poultices, etc.). Among those artificial
forms is reckoned that circumscribed eczema on the upper surface of
the crista helicis which occurs, usually symmetrically on both ears,
in persons who sleep on hard pillows of horse-hair. Acute eczema
often arises in the course of acute or chronic otorrhcea from the
action of the irritating secretion, especially in children and in indi-
viduals whose skin is easily irritated. In general, a scrofulous
dyscrasia and rachitis plays an important part in predisposition to
the formation of eczema.

Symptoms. — Acute eczema begins with a feeUng of heat, burning,
and itching, followed, after the appearance of the vesicles, by great
pain in the part affected. In the case of children, and more rarely
in adults, the disease is accompanied by slight pyrexia, restlessness,
and sleeplessness.

The function of hearing is normal in cases in which the eczema is
limited to the auricle ; in disease of the auditory meatus there occurs
a mechanical disturbance of hearing combined with subjective noises
caused by the swelling of its lining membrane, and by the desquama-
tion and accumulation of epidermis, exudation, and crusts. Rarely
a recent middle ear catarrh intercurs.

Course, — The course of acute eczema is in the majority of cases
typical. In slight cases the vesicles dry up quickly after the second
or third day, the epidermis then desquamates and recovery takes
place. More frequently, after the vesicles have burst, there is an
abundant discharge of clear secretion, which abates after several
days, and the parts laid bare become covered with light or brownish-
yellow crusts. In normal circumstances, when the exudation is at
a standstill, a new epidermis forms beneath the crust, which, after
the latter has peeled off, very soon assumes its natural appearance.
Sometimes, however, the exudation of clear or purulent fluid beneath
the crust continues for several weeks before the formation of a new
epidermic layer.

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190 BCZBMA OF THE EXTEBNAL BAB.

Besults, — ^Acute eczema generally ends in recovery, which some-
times takes place in a few days, but frequently not for some weeks.
The eczema sometimes heals on one part of the auricle or meatus
and breaks out on another. Repeated relapses, caused by the con-
tinuance of the cause, by general illness, or by extending eczema on
other parts of the body, occasion deeper tissue-changes in the cutis
and the transition of the acute into the chronic form.

On the line between acute and chronic eczema of the external ear is that
subacute form eczema crustosum and impetiginosom which is seen in young
children. The posterior surface of the auricle, the retro-auricular niche, the
sulci and depressions of the concha are affected, associated with an extensive
subacute eczema of the head and face, or from pediculosis capitis. This form
of eczema manifests itself by a specially profuse production of crusts and
scales, which are situated upon a very much congested and inflamed basis.
The intense itching, the excessive feeling of heat, and intolerable tension
cause the children to rub and scratch the ear, which produces pain and very
often bleeding injuries to the posterior surface of the auricle. On the other
hand, the resorption of the pus, which is confined xmder the adherent crusts,
often produces extensive disease of the skin, accompanied by fever and inflam-
mation and suppuration of the retro-auricular and cervical lymph glands.
The treatment described generally succeeds in quickly palliating this very
painful afiGaetionf and in preventing its ohaiDge into the chronic form.

Chronic Eczema is distinguished from the acute form by the deeper
tissue-changes in the cutis. While in acute eczema the inflanamation
is confined to the uppermost layer of the cutis, in chronic eczema
there is hypertrophy of the subcutaneous connective tissue which
leads to narrowing of the cartilaginous auditory meatus and conden-
sation, enlargement, and rigidity of the auricle. The secretion and
scabbing are localized in the depressions of the auricle and on the
posterior part of its attachment, while there is abundant desquama-
tion on the remaining parts.

Chronic eczema of the auricle and of the external meatus appears
most frequently as crusty or scaly eczema. The two forms may be
combined. The crusty form is characterized by the formation of thick
scabs, under which a serous or purulent fluid is exuded. It presents,
therefore, on the whole, the same phenomena as acute eczema in the
scabbing stage.

The scaly form of eczema is characterized by hyperaemia and
hypertrophy of the cutis combined with continued desquamation of
the epidermis. The affection is often combined with eczema of the
scalp, and is but rarely confined to the auricle or auditory meatus.
Squamous eczema may arise out of the chronic moist form, but it
occurs more frequently on the cutis as a scaly eczema without any

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CHRONIC ECZEMA. — SYMPTOMS. — COURSE. — DIAGNOSIS. 191

preceding serous exudation. In slight cases the desquamation is so
trifling that it is confined to a few depressions of the auricle or to
the parts surrounding the external orifice of the ear. In more severe
forms, however, the eczema spreads not only over the auricle and its
neighbourhood, but over the entire auditory meatus and the external
surface of the membrana tympani. In this case the auricle is enlarged
owing to the great infiltration of the cutis, and the meatus is narrowed ;
and in the depressions on the superior and posterior places of attach-
ment of the auricle as well as on the superior periphery of the external
orifice of the ear there are found ragged, slightly secreting fissures of
the skin which are difficult to heal.

Symptoms. — Of the symptoms of chronic eczema a troublesome
itching is the most constant, causing the patient to be continually
scratchmg the meatus with some hard instrument, thereby setting
up intercurrent painful inflammation in that canal. Subjective noises
are induced either by plugging of the meatus with desquamated scales
or by secondary hypersemia in the middle ear and in the labyrinth.
So, also, disturbances of the hearing may arise without mechanical
obstruction in the auditory meatus from simultaneous swelUng of the
mucous membrane of the tympanic cavity and of the Eustachian tube.

Course and Termination, — The course and termination of chronic
eczema vary according to the severity of the skin-affection. The
slighter forms, confined to the ear alone, may recover spontaneously
or disappear after short treatment, while the severe forms very rarely
recede spontaneously, and prove very stubborn to treatment. Even
when recovery is apparent, there is a relapse of the eczema sooner
or later. Sometimes there are intercurrent painful follicular inflam-
mations in the external meatus.

A rare result, although well known to dermatologists, of the chronic eczema,
especially with formation of crusts, is the true elephantiatic thickening of the
auricle, in pachydermia. Where there is a large increase of the connective
tissue in the parts joining the skin, an extensive lymph stasis occurs in the net-
work of the cutis, which produces a peculiar soft doughy feeling. Slight
mechanical injuries serve in these cases of elephantiatic thickening of the
skin to produce an eruption and are the source of frequent recrudescence of
the eczema.

Diagnosis, — The diagnosis depends on the above-described objective
signs. According to Auspitz it is possible to confound it with sebor-
rhoea of the external ear, but in the latter there is an absence of
redness and infiltration of the skin.

The prognosis of chronic eczema is favourable only as regards the
recurrence of exudation or desquamation in its slighter forms ; on
the other hand, in severe cases, compUcated with eczema of the

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192 CHRONIC ECZEMA. — TREATMENT.

scalp, or other parts of the body, and combined with hypertrophy of
the cutis, it is most unfavourable.

Treatment. — In the treatment of eczema of the ear, the causes
and the stages of the skin-affection must be considered. Although
acute eczema often heals spontaneously, it is necessary to avoid in
the acute stage all injurious irritation which keeps up the exudation
and impedes the growth of new epidermis. The patient must, there-
fore, be forbidden to wash the affected parts with water, or to syringe
the ear, while he is to protect the inflamed parts of the skin, or those
laid bare by the bursting of the vesicles, from the influence of the air
by painting them with ungu. emoUiens or vaseHne. Moist surfaces
on the auricle, especially intertrigo behind the ear, which occurs
frequently in children, are best covered with powder, or with pul-
verized calomel. The latter is recommended by Eohrer as well for
acute as the moist form of chronic eczema. The powder, however,
is not suitable for acute eczema of the auditory meatus on account
of the rapid obstruction of the canal. Cold compresses on the region
of the ear, with the addition of liq. plumb, acet. or liq. Burowi (with
10 times the amount of water) in combination with pencilling, with a
5 per cent. sol. of cocaine, are indicated only in extensive and painful
eruptions in the stage of vesication. Ichthyol, which has been lately
recommended, has proved useful in many cases, either in substance
or in aqueous and alcoholic solutions (1*0 inSO'O), and in the form of
an ointment (1 in 60).

When a patient presents himself for treatment at the scabbing
stage, the crusts must first be removed, in order, if possible, to
render remedies effectual on the diseased cutis. Forcible loosening
of closely adherent scabs or the rubbing of them off by means of dry
linen cloths I consider injurious, because I have observed the forma-
tion afterwards of new and thicker scabs, notwithstanding the use of
the most effective remedies. The crusts are best softened by the
application of vaseline, sweet oil, or of balsam of Peru, and may be
removed on the following day with a brush or forceps.

A very valuable method, on account of its peculiar property of
quickly macerating and loosening the adherent crusts, is the applica-
tion to the diseased part of Uquor Burowi in the above-mentioned
strength. It is necessary to carefully apply several layers of the
cloth used for the fomentation, and cover with some waterproof
material (gutta-percha cloth — Billroth cloth) to prevent evaporation.
If the compresses are changed every 2 hours, at the end of 24 to 48
hours the crusts are softened, so that they may be removed with a
pincette without hurting the patient, after which it should be dressed
with ointment.

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TBE^TMENT. 193

Then, without irritating the exposed parts further, the auricle,
with all its depressions, is painted with a medicated ointment. For
this purpose the following are the best : Hebra's diachylon ointment
(prepared with olive oil) : ungu. plumbi carbonatis and ungu. emol-
liens, aa. part, aequal. ; ungu. vaselin. plumb, (empl. diachyl. s.
vaselin. pur. aa. part. aequaL); ungu. acid, boraci (1 in 15 vasel.);
ungu. oxid. zinc. (1 in 30); Lassar's paste (zinci oxyd., amy! orizse.
aa. 10, vaseUn. 20*0); Pagenstecher's ointment (Hedinger). In
addition, both auricles are covered with fine linen spread with the
ointment. To produce complete contact, the cloth is pressed into
the depressions of the auricle, and particularly during the night by
putting on a wadding compress fixed by a light bandage. Small
pledgets, corresponding to the width of the auditory meatus, and
impregnated with the ointment, are pushed into the meatus. Those
as well as the dressing on the auricle must be changed every twenty-
four hours, and the ointment mixed with exudation should not be
washed, but carefully brushed ofiF. The salicyHc soap plaster (acid,
salic. 1 to empl. sapon. 10) introduced into dermatology by Pick has
proved very useful in the treatment of eczema of the auricle with
crusts, impetigo, and scales. This is also true of the Beiersdorf-
Unna mull, treated with ointment (zinc, bor. and salicylic acid),
and the recently recommended medicated tragant-gelatine, especially
the zinc and boric acid gelatine. The latter is used in a 5 to 10 per
cent, mixture once or twice a day. The medicated gelatine, without
warming, is painted upon the diseased part of the auricle, where it
hardens and forms a protective covering for the diseased portion.
The pencilling with 1 to 3 per cent, solution of silver nitrate in
eczema with crusts is useful only in obstinate cases.

After the crust is removed, the newly-formed epidermis is tender
and little resistant, and the cutis remains for a long time hyperaemic.
All irritation, therefore, which might destroy the epithelium and
increase the hypersemia of the cutis, must be avoided; frequent
washing and rubbing of the skin must be discontinued, as well as
syringing of the auditory meatus, and for several weeks these parts
of the skin should be anointed with a thin layer of vaseline, cold
cream, or a weak precipitate ointment (0*2 in 15).

Chas. Delstanche has observed very favourable and rapid healing after the
treatment as used by Delstanche, senr. This consists in syringing out the
meatus with a lukewarm saturated solution of plumb, acet., and the diseased
portions on the auricle are soaked with the same. After this the surface of
the eczematous places are rubbed with a piece of fine linen to remove the
crusts, and then the auricle is massaged between the fingers to soften it and
reduce the interstitial infiltration. To finish, the diseased portions are again

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194 ECZEMA OF THE EXTERNAL EAB.

washed in lead solution by means of the syringe. Between the treatments
the eczematous spots remain uncovered.

The treatment of squamous eczema is regulated by the intensity
of the desquamation and the amount of the infiltration of the skin.
In its slighter forms on the auricle, repeated painting with tinct.
rusci, carbolic spirit (1 in 30), an alcoholic solution of boracic acid
(1 in 20), or frequent cleansing with tar or soft soap (Auspitz), often
suffice to effect a cure. More severe forms with great thickening of
the epidermis and infiltration of the cutis, on the other hand, prove
very obstinate. If the epidermis is much thickened and indurated,
iu must be softened by the daily application of a 10 to 15 per cent,
salicylic soap plaster, or the fomentation vrith Liq. Burowi It is
necessary to wash more obstinate parts with a solution of potash
soap in spirit, in order to remove the indurated epithelium. The
use of mull saturated vdth gutta-percha plaster, alone or salicylated,
as recommended by Dnna, has proved very efficacious, as it can be
adapted to the form of the auricle, and adheres very tenaciously,
besides macerating and loosening the scales. Sometimes this method
alone is sufficient to heal a chronic scaly eczema, at least after using
this treatment for one or two weeks there is a marked lessening of
the rigidity and tendency to laceration of the skin, and a healing of
the fissures and clefts on the auricle. If after this time the skin is
not entirely smooth, tar may be used. The first proceeding consists
in rubbing ol. rusci into the reddened parts by means of a stiff
pencil, and this is repeated till the brown tarry scurf has been rubbed
off. When the skin has become smoother, more flexible, and paler
by this repeated painting with tar, it is time to employ the tar
ointment (ol. fagi 10*0, glycerine 5*0, ungu. emolliens 40*0), painting
VTith ol. cadini and glycerine (1 in 25), sulphur ointment (flor. sulph.,
ol. cadini, styrac. liq. aa, 10*0, ungu. diachyl. s. ol. amygdal. aa. 150),
ichthyol ointment (1 in 10 lanoline), carbolic ointment (1 in 40),
white or yellow precipitate ointment, ungu. Wilsoni (benzoic acid
5*0, ungu. commim. 150*0 ; strain and add oxid. zinci 25-0). Of
these remedies, sometimes the one and sometimes the other is
effectual, according to the case.

Amongst all the remedies for squamous eczema in the external
auditory meatus, painting with concentrated solutions of lunar
caustic is the most effectual. After the scales have been removed
from the walls of the meatus by means of a dry pellet of cotton-wool,
the solution is applied to them with a brush or a ball of cotton- wool.
The scurf falls off in one or two days in the form of blackish-brown
dry plates, leaving the cutis smooth and paler in colour. In slight
cases, the cutis resumes its normal appearance after having been

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HERPES ZOSTER. 195

cauterized two or three times. In more severe cases, combined with
great narrowing of the cartilaginous meatus, cauterizing requires to
be more frequently repeated (8 to 10 times), in order to allay the
swelling of the cutis. Fissures at the external opening of the ear
should be treated first with Lassar's paste or with salicylic soap
plaster, and if they show no tendency to heal imder this treatment
they should be touched with solid caustic.

After the caustic treatment it is necessary, in order to prevent
relapses, to anoint the cutis of the cartilaginous meatus twice a
week with a thin layer of white precipitate ointment, or with a weak
ointment of ol. cadini (1 in 40 vaseline), and to continue it for
some time. By that means the troublesome itching is most surely
subdued.

With the healing of the eczema, the disturbance of hearing and
subjective noises which accompany it frequently disappear, but not
always.

Internal treatment of aural eczema is almost superfluous. In
anaemic and scrofulous persons, especially children, the course of a
chronic eczema will be shortened by the internal use of cod-hver oil,
iron preparation, iodide of iron, arsenic (Fowler's sol. 3 to 10 drops
per day, with tinct. malat. ferri), or the waters containing arsenic,
Eoncegno, Levico, etc.

Among the rarer affections of the skin of the external ear are
reckoned pemphigus, herpes zoster, lupus, and psoriasis.

D. Herpes Zoster,

This affection is characterized by the painful development of trans-
parent vesicles grouped together on a reddened surface. The site is
either the posterior surface of the auricle, particularly the lobe, or
the region in front of the tragus, and the anterior superior wall of
the meatus, according as the herpes is caused by an affection of the
trigeminus (anterior surface), or of the great auricular nerve (posterior
surface), or the ganglion belonging to these nerves. Hartmann saw
a herpes eruption on the membrana tympani. The formation of these
vesicles is preceded by violent and rarely remitting pains in the head
and in* the neighbourhood of the ear, which continue for several days.
After the eruption appears, accompanied sometimes by fever, the
pain generally subsides, but it may also continue till the vesicles
dry up. Occasionally a paralysis of the facial nerve occurs on the
affected side, as I have observed in a few cases, at the time of the
eruption, and recovered in a few weeks after healing of the herpes.
Neuralgia, which usually remains after the termination of zoster

Digitized by VjOOQIC

196 HERPES ZOSTER.

along the intercostal nerves, I have only seen m one case, in which
it disappeared some weeks after recovery of the herpes.

The termination is recovery, as after bursting of the vesicles the
diseased parts become covered with a crust, which falls off on the
formation of a new epidermis.

Treatment consists in combating the violent pain by applying a
5 per cent, cocaine ointment, and by the internal exhibition of

Fig. 85.— Herpes Zoster ok the Auricle in a Child of 9 Years, as observed
BT Dr. Hermet in Paris.

quinine, antipyrine, or a narcotic, and when that is ineffectual, by a
subcutaneous injection of morphia. After the vesicles break, their
drying up is effected by sprinkling them with powder or anointing
them with unguent, plumb, acet. or plumb, carbonatis.

E. Luptis,

Lupus vulgaris of the auricle is often seen accompanying extensive
lupus of the skin of the face. Its occurrence alone limited to the
auricle is more rare. All known forms of lupus — L. maculosus,
exulcerans, hypertrophicus, papillaris, and framboisoides — occur on
the auricle according to which form it manifests on the skin of other
portions of the body. There occurs here, as in other parts of the
body, changes from one form to another. Generally one finds dis-
seminated plaques of lupus maculosus on the lobule, in the depres-
sion of the concha, or on the posterior surface of the auricle. It
appears in the form of brown tubercles the size of a pin-head or
lentil, covered with scales thickly grouped together, and penetrating

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LUPUS. 197

deep into the subcutaneous tissue. They seldom ulcerate, but by
their shrinking produce cicatrices in the skin. By the smaller size
of the efflorescence, the moderate amount of scales formed and the
characteristic shrinking so as to form hard, hypertrophied, and even
keloid scars, it is distinguished from psoriasis, which occurs on the
ear only, combined with extensive psoriasis of the skin on other
portions of the body.

Lupus exulcerans of the skin of the cheek often attacks the anterior
surface of the auricle, and forms here ulcers of different sizes, covered
with thick crusts, after the removal of which the base presents a
spongy, glandular appearance. The edge of the ulcer is often livid
and undermined. It is often possible to find in the edge of the ulcer
typical lupus nodules springing from the cuticular tissue, and not
yet ulcerated. The finding of these makes the diagnosis of lupus
certain.

The lupus of the auricle gives a very peculiar impression according
to Neisser, when the lobule is simultaneously affected, as it hangs
down from the auricle as a large pear-shaped tumour, and ulcerates
later than the other portions. Cases of lupus exulcerans limited to
the auricle appear to have been rarely seen. One case in my practice
affected an otherwise healthy young man, belonging to the better
class, and had existed for several months limited to the auricle. The
lupous ulceration appeared on the upper half of the auricle and
extended round to its posterior surfaca On individual parts of the
anterior surface, the skin was so completely destroyed that the
cartilage of the ear, suffused with blood, was quite exposed. The
sharply defined edges of the skin appeared spongy, soft, and bled
easily. By the repeated application of the sharp spoon and cauteri-
zation with solid argentic nitrate, a cure was effected after some
weeks* treatment, leaving, however, cicatrization and slight deformity
of the auricle. In a second case (a girl of 25 years), in which the
lupous infiltration took place from the lower part of the lobule
upwards, towards the posterior edge of the auricle, after several
months' energetic cauterization with solid nitrate of silver, it was
made to heal without leaving any deformity.

The lupus hypertrophicus (tumidus, papillaris, framboisoides) may
grow from the floor of the exulcerated lupus vulgaris, if it is neg-
lected and not properly treated. While the lupous destruction of
skin tissue progresses by the continual deposit of lupus nodules in the
deeper parts of the cutis, the excessively developed granulation tissue
upon the floor of the ulcer, in the form of glandular and papillary
growths, gives a deformed appearance to the affected auricle. Often
the granulations are of a spongy character, bleeding easily ; but only

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198

LUPUS.

seldom do they become hard on their surface, while the ulceration
continues at their base. These forms of lupus are the most malignant
and obstinate, as they produce the most extensive destruction of
the auricle. In especially protracted cases it goes on to inflanmiation,
ulceration, necrosis, and finally to a deformed contraction of the
whole cartilage of the ear, or more or less of the auricle is totally
destroyed (lupus mutilans).

Only rarely the localized lupus of the pharynx extends along the
tube to the middle and inner ear. Gradenigo has described such a
case in which it progressed to lupous destruction of the membrana
tympani, the ossicula, the mucous membrane of the cavum tympani,
and the vestibule.

The treatment of lupus vulgaris has in view : 1. The removal or
destruction of the lupus granulations ; 2. To guard against deformity.
In the ordinary non-ulcerative lupus the two objects will be most
easily obtained if only the true lupus nodules are destroyed by
cauterization and not the whole surface containing them. This is
best performed by pressing a pointed piece of limar caustic into the
nodules which are visible, as it easily penetrates the soft, rotten
tissue. This procedure is to be repeated imtil no recurrence of either
nodules or spots takes place. The consecutive cicatrization is rela-
tively small by this treatment, and the healthy skin between the
spots of infiltration are left intact. The same result is also obtained
by Hebra's cauterization with caustic potash and silver. After well
cocainizing the diseased portion, a 30 per cent, solution of caustic
potash is freely applied until the skin covering this portion is removed.
The surface is now quickly painted with a 25 per cent, solution of
nitrate of silver, which is prevented from running over the healthy
portion by means of moist cotton. The solution then penetrates
into the depth of the lupous infiltration, which it destroys without
injuring the healthy skin. It is better to cover the wounded part
with iodoform gauze for antiseptic reasons. Acetic acid, which
was recommended by Mosetig-Moorhof on account of its peculiarly
destructive action on diseased tissue, and not afifecting the healthy
tissue, may also be used in lupus of the auricle. Pencilling with
iodine-glycerine (1 in 2) and concentrated carbolic acid sxe of
subordinate value. Better results in protecting the skin may be
obtained by using pyrogallic acid, which is applied in the form of a
20 per cent, ointment several times during the 24 hours.

In all forms of lupus exulcerans the ulcerating surface should first
be thoroughly cauterized to remove the granulation growth. Spongy
and hypertrophied granulation growths must be removed with Volk-
mann's spoon, after which the base of the lupus should be cauterized

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SYPHILITIC INFLAMMATION OF THE EXTERNAL EAR. 199

with either solid argentic nitrate, or the galvanic or thermo-cautery.
By continued use of these methods of cauterization all the diseased
tissue may be destroyed and the progress of the disease stopped,
although it sometimes requires several months. Even if the forma-
tion of cicatricial tissue is considerable, and generally there is con-
siderable deformity remaining after the lupus exulcerans has healed,
the energetically used cautery is the only effective means by which
not only healing is brought about, but also the more extensive
deformity of the auricle is avoided.

Lupus erythematosus occurs on the free edge of the auricle and on
its posterior surface, accompanying lupus erythematosus of the face.
It progresses without ulceration to cicatricial atrophy of the cutis. In
its general extensive form, known as erysipelas perstans, the auricle
is always simultaneously affected. The ordinary chronic form of
lupus erythematosus is treated with applications of soft soap, painting
with iodine-glycerine (M. Richter) or by scarification, followed by
cauterizing with chloride of zinc (Veiel).

F. Syphilitic Inflammation of the External Ear.

Primary syphilitic affections in the region of the external ear are very
rare. In Lang*s lectures on * Pathology and Treatment of Syphilis,* p. 480
(Wiesbaden, 1885), are cited two cases, one by C. Pellizzari,* the second by
J. Zucker,f of which the location of one was on the lobule and the other on
the anterior wall of the osseous meatus. In both cases the cause of infec-
tion was easily foimd. In the first case the infection followed the use of a
handkerchief which had previously been used by the sj^philitic son of the
patient, the second case was produced by the too fervent love-caress of a
publican. A third case of primary syphilitic infection on the auricle is
reported by Hermet,J in a woman aged forty -two years, who acquired the
chancre through the caress of her own husband who was infected. The
report of a fourth case I owe to the friendly communication of Dr. Hermet,
in Paris, who saw a phagedenic chancre sclerosis on the lobule and the under
third of the auricle. The infection followed a bite on the auricle received in
a fight with a syphilitic individual.

Secondary syphilitic affections of the auricle in the form of squam-
ous, pustular, and papular eruptions occur only in general cutaneous
syphilis, and especially when the skin of the forehead and the scalp
are affected at the same time. Gummous syphilitic nodules are
seldom met with, but according to an observation made by Burnett,
they may spread over the entire auricle, and by the formation of
deep-seated ulcers partially destroy it.

• Virch, Arch., vol. Ixix., p. 313.

t ZtiUchrift. f. Ohrenh. vol. xiiL, p. 171.

t Annales de Dermatologie e( dt Syphilographie, 2eme S^rie, Extrait.

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200 SYPHILITIC INFLAMMATION OF THE EXTERNAL EAR.

Of the syphilitic affections occurring in the external meatus, con-
dylomata and ulcers have been the most accurately studied.* Con-
dylomata in the auditory meatus occur only in general syphilis, and
often with condylomata at the same time on other parts of the body.
They usually occur simultaneously with general symptoms of syphilis
(Stohr, A. f, 0., vol. v.) ; i.e., with signs of syphiHtic affections of the
skin, pharyngeal ulcers, and glandular sweUings. Occasionally con-
fluent condylomata occur in both auditory meatuses (Noquet, Bevvs
mensuelle, July, 1885).

The initial stage of condylomata as a rule escapes observation on
account of the absence of striking symptoms. According to Knapp
{Z. /. 0., vol. viii.), they commence with reddish, gradually-increasing
efflorescences in the meatus, followed by diffuse swelling of its walls,
with moderate secretion. On the secreting parts the condylomata
spring up, more or less quickly, in the form of reddish or grapsh-
red, ragged, warty excrescences, which extend from the entrance of
the ear to the osseous meatus, and render the lumen of the canal
quite impermeable. In one of my cases the condylomata were
limited to the parts of the cartilaginous section bounding the orifice
of the ear. In another case the condylomatous growth could be
followed nearly to the membrana tympani.

While the initial stage runs its course without symptoms, violent,
radiating pains, increased by movement of the jaw, appear with the
formation of the condylomata, and especially with their ulceration ;
only in occasional cases is there any fever (Stohr). Subjective noises
and deafness are caused either by mechanical obstruction of the
auditory meatus or by consecutive affection of the middle ear, which,
as in a case observed by Knapp, may be associated with bilateral
perforation of the membrana tympani.

Condylomata of the auditory meatus either heal by resolution,
which quickly follows on energetic general treatment and the sup-
pression of the other syphilitic symptoms, or end in destruction o{
the efflorescences with profuse, foetid secretion and the formation of
unhealthy, confluent ulcers, seated usually on the inferior posterior
wall, and healing very slowly. By rational local and general treat-
ment, cure follows after some weeks or months, with or without
cicatrization. In the latter case that portion of the meatus appears
sunken and devoid of hairs. Stricture of the meatus seldom remains.

• Among 1,200 ayphilitic patients, of whom 980 had cimdylomata, Despr^ {Ann,
d. Med, de rOr,, etc., 1878) observed condylomata in the external meatus five times.
Buck (Am. Jounu of Otol.^ 1879) among 4,000 persons with ear disease met with 30
cases of syphilis of the ear, 5 of which suffered from condylomata and ulcers.
Kavogli (CongresHher, Mailand, 1880) among 144 cases of syphilis found the middle
ear affected fifteen times and the external meatus only once.

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SYPHILITIC INFLAMMA.TION OP THE EXTERNAL EAR. 201

The diagnosis of condylomata in the auditory meatus, which can
be confoimded with granulations only on superficial observation,
depends on the simultaneous existence of the characteristic symp-
toms of sjrphiUs on the genitals, the skin, and the throat, and on the
accompanying glandular sweUings.

The prognosis of condylomata of the auditory meatus is favour-
able.

The papular syphilitic infiltration may occur on the external surface of the
membrana tjTiipani, as observed by Lang (I. c, p. 481), who saw a large
pale, glancing papule in the position of the short process of the malleus in
a female with a recent general syphilis. The anterior superior quadrant of
the membrane was greatly injected and the whole membrana tympani was
opaque. Conversation could only be heard at the distance of five paces.

Gummous syphihtic ulcers seldom attack the external ear without a
simultaneous affection of the middle ear. Alb. H. Buck (Am. Joum,
of OtoL, 1879) records several cases of S3rphiHtic ulceration on the
auricle and in the meatus, with characteristic base and steep,
elevated margins. The occurrence of nasal and pharyngeal syphilis,
and the infiltration of the cervical glands at the same time were
evidence of the specific nature of the affection. Hessler {A, f. 0., xx.)
saw partial necrosis of the auricle following an ulcerating gumma.
In a case communicated by Eavogli (Z. c.) of a nodular syphilide on
the side of the neck, several syphilitic nodules were developed in
the meatus and on the membrana tympani, which formed angry,
isolated ulcers with deep base and elevated margins. Baratoux
observed a gummatous infiltration in the lower part of the left mem-
brana tympani.

In a case observed by me, a characteristic ulcer formed on the
inferior wall of the meatus in the course of chronic suppuration of
the middle ear. The fatty base of the ulcer occupied the anterior
and lateral walls of the cartilaginous portion, and its steep, elevated
margins involved the external orifice of the ear. The simultaneous
occurrence of pharyngeal syphiUs left no doubt as to the syphilitic
nature of the disease. In a second case there was, in addition to
an ulcer occupying the whole length of the cartilaginous wall of the
auditory meatus, a second round one with elevated edges in the
concha.

Syphihtic inflammation of the throat is well known to transmit
itself to the middle ear. Either catarrh occurs with impermeability
of the Eustachian tube and accumulation of serum or mucus in the
middle ear, or the ulceration extends to the cartilage of the tube,
whereby a portion of it is destroyed, leading to subsequent contrac-
tion or adhesion of the tube. Moreover, simple as well as ulcerative

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202 OTHEMATOMA.

syphilitic inflammation of the pharyngeal cavity may lead to purulent
otitis media with perforation of the membrana tympani ; but exami-
nation with the aural speculum seldom reveals a condition differing
from the common forms.

The treatment of condylomata of the auditory meatus consists,
besides general treatment, in several (3-6) cauterizations of the
granulations with limar caustic or concentrated solutions of chromic
acid, and, after reduction of the warty growths, in anointing them
with corrosive subhmate solution (0-1 in 30-0), or tincture of iodine.
Knapp recommends dusting the condylomata with calomel and after-
wards painting with a 1 per cent, solution of nitrate of silver. In
ulceration of the auditory meatus it is recommended to paint the
ulcerated parts several times with tincture of iodine, and when the
ulcer has lost its fatty appearance, to apply to it camphorated oil.
In one case cicatrization was brought about by keeping a plug of
mercurial plaster in the meatus.

III. — Diseases of the Perichondrium and Cartilage of the
Auricle and External Meatus.

1. Othematoma {Hcematoma Auris).

Othsematomata arise from a sudden effusion of blood between the
cartilage of the ear and the perichondrium, by which the latter, with
or without destruction of its continuity, is extensively separated from
the cartilage. As the cartilage of the ear is traversed by numerous
vascular bands of connective tissue (Pareidt), it is probable that by
violent pulling an othaBmatomata with partial tearing of the carti-
lage may be occasioned by the rupture of these ves^ls (Haupt,
Dissers, inaug., Wurzburg, 1867).

Etiology. — OthaBmatomata most frequently arise from injury, seldom
spontaneously. In a case described by Brunner {A. /. 0., vol v.), the
cause was ascribed to long contact of the auricle with a cold pane of
glass. The fact that often after violent pulling the auricle remains
intact, while at other times a shght pull suf&ces to give rise to an
escape of blood, renders it probable that certain tissue-changes in
the cartilage, especially in old and tubercular individuals, are the
predisposing cause of the othsematoma. As such are given by L.
Meyer, Pareidt, Haupt, Leubuscher, Simon, Virchow, and J. PoUak,
the following degenerations of the cartilage of the ear : softening
and fissure, the formation of cavities with gelatinous homogeneous
contents, proliferation of vessels and new formations. In one case

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OCCURRENCE. — SYMPTOMS. 203

of left-sided othsBmatoma I foiind on the right ear, corresponding to
the affected portion on the other side, an opaque thickening of the
cartilage, 4-5 nun. in size, which led one to conclude there was a
symmetrical tissue-change predisposing to othaBmatoma. It might
be imagined that repeated injuries could give rise to such changes
in the cartilage, that at last a little violence would cause an effusion
of blood.

Among the twenty-seven cases observed by Brigade-surgeon E.
Ghimani in the course of fourteen years, twenty-one were traumatic
and six spontaneous in origin. In nineteen cases of the first category,
in which the cause was positively ascertained, the othaematoma in
the left auricle was due nine times to a box on the ear, twice to a
blow with the fist, once to pulling, and once to a blow with a bayonet-
sheath ; in the right ear, twice to a box on the ear, three times to
blows, and once (complicated with rupture of the membrana tympani)
to plimging into water from a considerable height. In the two re-
maining cases of othaematoma of the left auricle, it was doubtful
whether they had been caused by a box on the ear or other-
wise.

Of the six spontaneous othaematomata, four were on the left, and
two on the right auricle. Of the individuals between twenty-one and
twenty-six years of age, five were perfectly healthy, and only one
debilitated by the cachexia of intermittent fever. Twenty-one cases
were dismissed cured ; in five the auricle was more or less deformed,
and in one the cartilage of the ear was for the most part lost by
ulceration.

Occurrence. — Othasmatomata occur in healthy individuals, remark-
ably often, however, in imbeciles. The left auricle is more frequently
affected, seldom both (Hun). While Gudden affirms, from the fact
of its being most common on the left side, that it is solely caused by
injury (ill-treatment), Simon believes {Berl. KL Wochenschr., 1865 j
that in imbeciles it is always caused by tissue-changes in the auricle.
Boosa {I. c.) connects othaematoma in imbeciles VTith disease of the
brain, relying upon the experiment of Brown-Sequard, who observed
the occurrence of haemorrhage in the auricle after severing the resti-
form body in animals.

Symptoms, — Othaematomata appears at the commencement as a
bluish-red swelling on the anterior surface of the auricle, rounded or
irregular, doughy or hard to the touch. They are seldom distinctly
fluctuating on the anterior surface and more rarely on the posterior
surface. Spontaneous othaematomata rarely attain the size of the
traumatic. While the former occupy only small sections of the con-
cave surface of the auricle, especially the concha and the intercrural

Digitized by VjOOQIC

204 OTH-EMATOMA.

fossa, the traumatic variety covers the whole anterior surface of the
auricle, the swelling sometimes occluding the external auditory
meatus, and, as I have seen in one case, it may spread itself on the
posterior surface of the auricle, crossing over the superior margin of
the hehx. In transmitted light the portion where the haemorrhage
is appears dark and opaque.

Spontaneous othsematomata often develop without any subjective
troubles, while the traumatic is mostly associated with great pain,
feehng of heat, and tension. By the addition of reactive inflammation
severe pain is also felt in a later stage of spontaneous othaamatoma.
Subjective noises and disturbances of hearing are only observed when
the auditory meatus is occluded by the swelling, or when the mem-
brana tympani is injured.

Course cmd Termination. — The course of othaematoma depends on
the extent of the haemorrhage and the degree of the lesion of the
cartilage. When the latter is not much altered by the haemorrhage
the termination is far more favourable than when the cartilaginous
tissue is fissured by the efiPusion. In some cases recovery takes place
by absorption without malformation of the auricle, while in other
cases the latter remains greatly deformed by cicatricial thickening,
atrophy, and shrivelling of the cartilage and skin. In a few cases,
and more commonly in the traumatic than in the spontaneous form,
there occurs an extensive inflammation of the cartilage, which
becomes covered with a bloody, gelatinous, and afterwards purulent
exudation that may lead to partial ulceration and multiple perfora-
tion of the cartilage and of the cutis, and even partial loss of the
auricle, or cicatricial deformity of it, with a clefted narrowing of the
meatus. Fatal results from pyaemia occur very rarely after
gangrenous degeneration.

Diagnosis, — The diagnosis of othaematoma can be made with cer-
tainty when it can be proved that the affection commenced suddenly
after an injury. In the spontaneous form the rapid development of
the swelling determines the diagnosis, considering that it is im*
possible to confound it with perichondritis auriculae, angioma, or
a neoplasm.

Prognosis. — The prognosis of traumatic othaematoma is, owing
to absorption without malformation of the auricle, more favour-
able than that of the spontaneous form, those cases being excepted
in which, through injury, there is a deep-seated lesion of the car-
tilage. It is a favourable sign when the swelling decreases during
its course without reaction, but unfavourable when violent inflam-
matory symptoms are superadded, which require the swelling to be
opened.

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TREATMENT. 205

Treatment, — In the case of small, painless tumours, it is best not
to interfere, as all treatment, such as pressure, embrocation, etc.,
rather tends to renew the bleeding than to quicken the absorption
of the extravasation. For this reason, therefore, massage, recom-
mended by Meyer (^4. /. 0., xvi.), must be used only with great
caution, and by no means at the beginning, but first in the third or
fourth week. When the swelling' is painful neither pressure nor
massage must be used. On the other hand, m traumatic and in
inflammatory othsematoma, cold compresses, by means of ice-bags,
or Leiter's apparatus, are advisable, and on the cessation of pain,
applications of Goulard's lotion. When, notwithstanding anti-
phlogistics, pain still continues after four or five days, and the
swelling has not decreased in size, puncture, letting out the contents,
and moderate pressure is the surest method of curing the disease.
In many cases the cavity refills with blood, or viscid fluid, so that
repeated puncture becomes necessary. When the tumour is of large

Fw. 86. — Spontaneous othematoma on the upper portion of the auricle, occurring in
» man aged 23. Puncture of the painful tumour ; breaking through the cartilage.
Healing of the returning processes b^ repeated injections of argentic nitrate sol.
(2-4 in 10), after its existence for three months.

circumference, R. Chimani recommends the splitting of the swelHng,
the removal of its contents, and the insertion of carbolic or salicylic
wadding or iodoform gauze into the cavity, and afterwards a com-
press bandage.

Hflemorrhage in the external auditory meatus is most frequently
caused by traumatic injuries of the cutis or of the cartilage, and by
fracture of the osseous walls. Spontaneous hasmorrhage is rare,
and arises usually in those idiopathic forms of inflammation which
we describe as otitis externa hsemorrhagica.

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206 PERICHONDRITIS OP THE AURICLE.

2. Perichondritis of the Auricle {Perichondritis Auricula),

Perichondritis is more rarely met with than was formerly supposed.
It develops without any known cause, and affects the anterior
surface of the auricle without involving the lobe, this being the
characteristic of this form of inflammation.

The auditory meatus either remains intact, or the inflamma-
tion begins in it and extends to the auricle. In a case observed
by Knapp, the affection was complicated with otitis media per-
forativa.

Symptoms, — At the acme of the inflammation, a red or bluish-red,
uneven, fluctuating swelling is found on the anterior surface of the
auricle, occupying the greater part of the concha and the fossa
helicis, and appearing sharply demarcated below from the margin of
the lobe. The temperature of the auricle is increased during the
first stage. At first it seems very similar to othsematoma, but it
differs from the latter in its gradual development with inflammatory
phenomena and in its contents, which consist of a synovia-like or
purulent fluid, but not blood. After long duration of the tumour, it
becomes difficult to distinguish it from othsematoma, because the
latter in its later stages sometimes contains no blood, but only a
transparent syrupy fluid. Probing the incised tumour reveals a
more or less extensive loosening of the perichondrium and denuda-
tion of the uneven rough cartilage.

The terminations of perichondritis are : recovery after the forma-
tion of an abscess, and discharge of the synovial fluid mixed with
pus, without the shape of the auricle being changed (Chamani), or
shrivelling and marked deformity of the cartilage, as is observed in
the worst forms of othsematoma (Knapp). In the cases observed,
the course was slow, and in one recorded by Knapp, in which the
inflammation originated in a furuncTilar swelling in the meatus,
repeated formation of tumours on various parts of the auricle took
place. Also in a case of Benni's during a course of three months,
the circumscribed perichondritis travelled over the whole anterior
surface of the auricle, with exception of the lobule. A similar
course was shown in a patient in my clinic occurring in a young girl
of otherwise good health. Schwartze saw calcareous and cheesy
degeneration result in a case of his. Knapp (Arch, of Otology, 1890)
saw true ossification occur in a girl of 22 years, following sero-
purulent perichondritis. The duration of the inflammation varied
from three weeks to three months.

The treatment of perichondritis consists at first in the energetic
application of antiphlogistics (Leiter's coil), and the early incision

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CONTRACTIONS OF THE EXTEBNAL AUDITORY MEATUS. 207

of the fluctuating tumour. Burckhardt-Merian and Urban-Pritchard
saw rapid healing take place after puncture, followed by injections
of diluted tinct. of iodine (with alcohol aa.). The succeeding treat-
ment by antiseptics, and the application of a pressure-bandage is
analogous to that already referred to in the treatment of othsBma-
toma. Kuhn recommended massage, which proved better, in two
cases of his, than puncture and injection.'*

As extremely rare occurrences, we must mention gangrene of the
auricle (PoUtzer, Kurckenberg, Eitelberg, Nottingham), and the
cases of noma observed by Hutchinson [Med, Times cmd Gazette,
1881). After removal of the necrosed parts and cauterization with
nitrate of mercury, recovery followed in the latter case. There is
further the affection called by Wilde (I c, p. 208) pemphigus gan-
grsenosus, which appears behind and on the ears, and is met with
frequently among the lower classes in Ireland ; it is phagedsenic in
character, and generally terminates fatally. Bohrer observed a case
of simple pemphigus with formation of bullae as large as a hazel-nut.
Jansh and Chiari have also observed a case of a tubercular ulcer
of the skin on the left auricle of a phthisical patient.

IV. Contractions and Adhesions of the External Auditory

Meatus.

Contractions in the external auditory meatus are caused by infil-
tration and bulging out of its lining membrane, by cicatrization, or
by hyperostosis and osseous new formation on the walls of the
meatus, and other forms of new growths. The contractions caused
by swelling and hypertrophy of the cutis most frequently develop in
the secondary inflammations during the course of chronic suppuration
of the middle ear, and further in chronic eczema and in the primary
forms of otitis externa. Cicatricial strictures occur in chronic
secondary inflammations of the meatus in the course of lingering
suppurations of the middle ear, after diphtheritic and syphilitic
ulcerations, after injuries and cauterizations (with concentrated
acids, galvano-cautery, soHd lunar caustic) of the Hning membrane
of the meatus, and after unskilful sewing of a separated auricle
(Bishop, of Chicago). A fissure-like contraction of the orifice of the ^
ear, caused by atrophy, shrivelling and collapse of the cartilaginous
wall of the meatus is very frequently met with in old persons.
Moure saw a similar narrowing of the cartilaginous meatus in French

♦ Wilde, Prctct, Bemerkungtn Uber Okrenheilk, Deutsch, Ueber., 1865; R. Ghimani,
A. /. 0. Bd. ii. ; H. Knapp, Z, /. 0, Bd. x. ; O. D. Pomeroy, Transact, of the
Amer, Otol. Soc.t ix, ; Benni, Baader Congressherickt,

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208 CONTKACTIONS OF THE EXTERNAL AUDITORY MEATUS.

peasant-women and nuns, owing to tightly fastening the cloth or the
cap around their heads*

The contractions are either temporary or permanent. Among the
first are reckoned the swelling of the cutis, caused by inflam-
matory infiltration, which, not only in the acute, but also in the
chronic forms, recedes spontaneously or after suitable treatment.
Sometimes, however, in long-continued infiltration of the cutis, par-
ticularly in the course of chronic suppuration of the middle ear,
there occurs a new formation of connective tissue with permanent
thickening and condensation of the tissue of the cutis, associated
with a considerable contraction of the lumen of the meatus.

The strictures caused by ulceration and cauterization are some-
what different. In some few cases there are circumscribed annular
strictures, which, as in a case observed by Morpurgo, are like the
diaphragm in an optical instrument, enclosing an orifice from the
size of a pin-head to that of a small lentil. This condition may
easily be mistaken for perforation of the membrana tympani when
the slight distance of the new-formed membrane from the external
orifice of the ear is overlooked. In other cases permanent strictures
remain from extensive callous condensation and shrivelling of the
subcutaneous connective tissue, mostly situated in the middle and
cartilaginous sections. The contraction is either circumscribed,
then affecting generally the middle of the meatus, or it is long,
extending usually from the neighbourhood of the external orifice of
the ear to the osseous meatus.

Osseous strictures are caused either by a more or less regular
periosteal ossification of the walls of the meatus, or by hyperostoses
proceeding from the posterior superior wall of the osseous meatus,
which, like an inclined plane, sinks from without inwards towards
the inferior wall of the meatus, and obstructs the view of the mem-
brana tympani by forming a fissure- like contraction of the lumen of
the canal. Such strictures, usually associated with great deafness,
frequently develop after carious processes in the temporal bone,
especially after exfoliation of large osseous sequestra from the
mastoid process through an opening in the wall of the meatus. The
slit-like contraction of the meatus, formed by the abnormal inward
curvature of its anterior inferior wall, is traced to an anomaly of
formation.

The form of the stricture of the meatus is round or fissiu-e-like,
seldom like an hour-glass. After exhausted suppuration the con-
tracted part remains long unchanged ; in the secreting stage, how-
ever, its size varies by the deposition of secretion and by increase
and decrease of the swelling of the cutis.

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CONTEACTIONS OP THE EXTERNAL AUDITORY MEATUS. 209

Contractions of the external meatus, even when very pronounced,
occasion deafness only when accompanied by pathological changes
in the middle ear, or accumulation of thickened secretion behind the
stricture. During the existence of suppuration of the middle ear
stricture may occasion a fatal affection of the brain or sinus by
retention of the pus (Ome Green, Roosa).

In the examination of strictures of the meatus careful probing
of the contracted parts is indispensable. For it not only shows the
difference of the membranous stricture from the osseous, but also
indicates the length of it. If it be short, the point of the probe will
move with much more freedom behind the contracted part than
when it is long.

The treatment of strictures of the external meatus depends on the
anatomical cause of the contraction and on the condition of the
parts of the external and middle ears lying behind the stricture.
In contractions caused by swelUng or hypertrophy of the cutis —
when they cannot be removed by the treatment spoken of under
inflammations of the external meatus — it is advisable to dilate the
contracted parts gradually by the insertion of conical, resistant plugs
of charpie, which are gradually increased in size. Should the latter
prove insufi&cient, compressed sponge tents should then be introduced,
gradually increasing in diameter and allowed to remain till moderate
pain is caused by their swelling. This is, as Gottstein rightly observes,
preferable to dilatation by means of laminaria tents, which by swell-
ing too quickly often occasion violent reaction and subsequently
greater contraction. Energetic attempts at dilatation may even have
as their result adhesion of the walls of the auditory meatus, when
the epidermic surface is torn off by the pressure of the dilator and
the exposed parts touch each other. Rapid dilatation is, however,
necessary when it is a question of removing stagnating secretion
from the deeper sections of the meatus and of the tympanic cavity
in order to check its deleterious effects. By inserting a shortened
tympanic tube 10 cm. long into the deeper part of the meatus,
and using injections of warm water, such secretion may be most
surely removed. The wearing of short vulcanite or silver canulae ic
recommended also in the case of fissure-like contraction of the
external orifice of the meatus, caused by collapse and atrophic
shrinking.

Long-continued contractions caused by hypertrophy of the lining
membrane of the meatus prove very obstinate to the methods of
dilatation described, as after repeated use of the compressed sponge
the contraction again reaches its former degree ; sometimes even it
increases in consequence of the mechanical irritation. In such ca«es,

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210 CONTRA.CTIONS OF THE EXTERNAL AUDITORY MEATUS.

as well as in cicatricial strictures, repeated longitudinal scarifications
of the cartilaginous meatus, with subsequent introduction of com-
pressed sponge tents, and the wearing of conically-shaped hard
rubber canulas (Fig. 87) prove very effectual. In a number of
cases a gradual dilatation was accomplished by wearing tubes
of 4-5 progressing sizes. The length of the tube corresponds to
the depth of the stricture in the meatus, and can be introduced
by the patient himself. Diaphragmatic septa may be permanently
removed by circular excision (Ladreit de Lacharri^re, Schwartze).
Long osseous strictures are incurable, and the method of chiselling out
proposed by some is not only useless but dangerous. By progressive
but not energetic attempts at dilatation by means of the compressed
sponge, continued for months in many cases, slight enlargements may
be attained. Too energetic attempts may have an opposite effect.
With doubtful symptoms of retention of pus the chiselling away of
part of the meatus wall or opening of the mastoid process is
advisable (Schwartze).

Contractions of the meatus are frequently caused by Exostoses of
the external meatus.
Hedinger regards exostoses in general as the result of a hyper-
trophic inflammation of the lining membrane
of the meatus with ossification of the new-
formed connective-tissue. Cassells {Transact,
of the Intemation, Med, Gongr,^ London, 1881)
differentiates two kinds of osseous new-forma-
tion : hyperostoses and exostoses, the first a
hyperplasia, the latter a new growth.
Fio. 87. According to v. Troltsch, no sharply-defined

line separates the exostoses from the hyper-
ostoses, but he applies the former term to those diffuse osseous
growths occupying the whole length of the meatus, and exostoses
to the circumscribed, tumour-like osseous new-formations.

The structure of exostoses are either compact, spongy, or hollow.
A pedunculated exostosis which I removed showed on histological
examination here and there compact lamellsB (ebumation) with a
few vessels.

Etiology, — The originating causes of the exostoses are in the
majority of cases not ascertained, because there is very little oppor-
tunity of observing their development clinically. The following may
serve as the origin of a series of cases: 1. Partial hyperplasias during
the stages of development and ossification of the osseous meatus.
To this form, according to my idea, belong those bilateral osteomata
arising without symptoms seated symmetrically in the aural

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CONTRACTIONS OP THE EXTERNAL AUDITORY MEATUS.

211

Fig. 88.

passages, and agreeing on the two sides in regard to form. Their
site is the middle and inner sections of the osseous meatus. They
are sessile or pedunculate, but never reach such a size as to com-
pletely fill the meatus. 2. Girctunscribed, chronic periosteal inflam-
mation in the osseous meatus. To these belong the round exostoses
(Osteophytes) which, according to Wagenhauser, occur from trau-
matic fractures of the anterior wall of the meatus. 3. Diffuse inflam-
mations of the external meatus, whether primary or developed in the
course of chronic suppuration of the middle
ear. Among these are to be reckoned the
ossification of new cartilaginous growths and
polypi, and the exostoses in the meatus ob-
served after middle ear suppuration (Dalby).
4. Hereditary tendency (Schwartze). 5.
Syphilis (Roosa) and gout (Toynbee) are much
more rarely the cause of exostoses than was
at one time supposed. That either of these
general diseases has given rise to the aural
affection can be considered probable only when osseous tumours
appear simultaneously on other parts of the body, the origin of
which can be traced to the general disease.

Moos describes (A, f. A. u, 0., ii.) three cases of symmetrical,
bilateral exostosis on the superior wall of the meatus, in which two
white nodules larger than hemp-seed were seated to the right and
left of Shrapnell's membrane. I have noted a number of such in my
practice (Fig. 88).

It must, however, remain imdecided whether one is here dealing with an
osteoma or with a solid connective-tissue tumoui*. I examined, indeed, more
than a thousand skulls and temporal bones without having met with any
similar formation in the meatus, and there is just as little information as to
such conditions on macerated temporal bones to be ob-
tained from other sources.

The frequent occurrence of exostoses of the meatus
among the aborigines of America has been repeatedly
confirmed by the investigations of Seligman, Flower,
Bernard Davis, Blake, Turner, and Virchow. C. J. Blake
also found, while examining numerous skulls of the Mound
Builders, exostoses in the auditory meatus in 25 per cent.
Virchow found among 184 Peruvian skulls exostoses in
eighteen. According to Virchow the location of the
exostoses was always the external portion of the bony meatus, and without
exception the edge of the pars tympanicus of the mastoid bone ; in the inner
portion they are never seen, according to Virchow.

Symptoms. — Exostoses of the external meatus appear as whit6

Fig. 89.— Pkdcn-
cuLATKD Exos-
tosis REMOVED
WITH A Chisel
from the lowek
Wall of the
Meatus.

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212 CONTRACTIONS OP THE EXTERNAL AUDITORY MEATUS.

or yellowish, usually smooth, tumours of various size, seated on
the wall of the meatus, either with a broad ill-defined base or
sharply demarcated and circumscribed. They may originate in any
point of the meatus. Frequent sites of exostoses are the place of
union of the osseous with the cartilaginous section and the posterior
wall of the meatus (Delstanche, Gardiner-Brown), especially its
external section covered by the cartilaginous portion. Exostoses
growing on this part are often seen with the naked eye immediately
behind the external orifice of the ear, and attain such a size that
they convert the lumen of the meatus into a narrow slit. By
pressure of the new-formation on the cartilaginous wall, the latter
atrophies, till it disappears altogether, or the exostosis adheres to
the cartilage so completely that the tumour may be mistaken for
an ossifying enchondroma. In a preparation described by Noltenius
an exostosis the size of a bean arose from the lower anterior border
of the pars tympanicus by means of a small pedestal, and filled the
external opening of the osseous meatus.

Exostoses may occur singly or in numbers in the meatus. Often
there are found two exostoses, which contract the meatus to a
fissure or to an hour-glass shape, completely masking the membrana
tympani or allowing only a small portion of it to be seen. Some-
times a small exostosis is placed on the top of a larger one (Moos).
Bilateral exostoses are very frequent, but not always symmetrical
on the same part of the meatus. Ayres saw symmetrical exostoses
in the form of a septum in both meatuses. Once I observed on the
left two and on the right three exostoses in the osseous section,
proceeding from the anterior, superior and posterior walls ; great
deafness and tinnitus had lasted since a confinement thirty-one
years before. As simultaneous changes in the ear, I have found
most frequently chronic catarrh of the middle ear without evident
connection with the osteoma, chronic suppuration of the middle
ear with or without polypi in the meatus, chronic otitis externa
with moderate desquamative secretion and chronic eczema. There
are very rarely simultaneous exostoses on other parts of the body.
In a Greek, aged forty-four years, who had never suffered from
syphilis, there existed, besides an exostosis almost completely
closing up the left meatus, an osseous tumour as large as the fist
on the left temple, which had gradually reached this size in the
<K)urse of twenty-four years. In general the examination of patients
shows a stationary condition of the exostosis, after a pause of several
years. Only occasionally, in suppurative processes, the bony growth
may rapidly increase in size. Those cases of spontaneous absorp-
tion of exostoses described in the literature are most likely to have
been an unorganized periosteal exudate.

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DIAGNOSIS. — TREATMENT. 213

The subjective symptoms accompanying exostosis of the meatus
are more often caused by simultaneous affections of the middle
ear and of the meatus than by the tumour itself. Small exostoses
not occluding the canal almost always nm their course without
sjrmptoms. Large osseous tumours, on the other hand, may give
rise to painful inflammation with suppuration by pressing on the
opposite wall of the meatus, the exostosis itself being also similarly
affected. In such a case I once observed a bed-sore, as it were,
with formation of granulation tissue arise on an exostosis. In a
case observed by Moos a trigeminal neuralgia was produced by an
exostosis which disappeared upon removal of the growth.

As to the further history of exostoses, large ones may, apart from
deafness, be injurious by favouring the accumulation of cerumen
and epidermic masses in the deeper parts of the meatus, by closing
it up and preventing the exit of pus in cases of co-existing suppura-
tion of the middle ear, and by rendering the surgical removal of
polypi difficult.

In a case of exostosis observed by Delstanche, which obliterated the
external opening of the meatus completely, the growth was fastened to the
posterior osseous wall of the meatus by a rather wide base, and showed some
movement. The cause of the latter was found after the operation to be due
to the softening and absoption of the upper and posterior osseous wall of the
meatus by the retention of pus, so that only a small portion remained, upon
which the exostosis was situated. If this had existed longer, the suppura-
tion would undoubtedly have produced a spontaneous expulsion of the
exostosis.

Diagnosis, — From its characteristic appearance, in my experience
the diagnosis of exostosis presents no difficulty. It is only when
the lining membrane of the meatus is inflamed and swollen that
the red, secreting swelling which may be covered with granulation
tissue can be mistaken for the bulging cutis of the meatus or for
a polypus. The resistance of the tumour and its usual sensibility
on being probed leaves no doubt as to its nature.

Treatment, — When exostoses have attained such a size that great
deafness is caused by the complete closure of the meatus, it is
better, before proceeding to surgical means, to make some attempts
at dilatation. If solid bodies introduced between the exostosis
and the wall of the meatus and retained there for a long time
succeed in causing atrophy of the exostosis and so establishing a
small slit in the lumen of the auditory meatus, that is quite enough
for the entrance of the waves of sound. Bonnafont {Union m^d.,
1863) describes three cases of extreme deafness from exostosis of
the meatus, in which normal hearing was restored by a very small

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214 CONTRACTIONS OP THE EXTERNAL AUDITORY MEATUS.

opening being formed through the long-continued introduction of a
metal rod between the meatus and the exostosis. Von Troltsch has
observed the circumference of an exostosis decrease after laminaria
tents had been introduced for years. In one case, where a piece
of the laminaria remaining had caused superficial necrosis of the
walls of the meatus, after removal of the small sequestrum a con-
siderable dilatation of the meatus was observed and the hearing
returned.

The removal of cerumen and epidermic masses accumulated
behind the exostosis by the ordinary syringing is seldom possible,
as the stream of water does not enter the opening with sufl&cient
force. In such cases, the desired result is most speedily attained
by pushing the point of a tympanic catheter through the opening
towards the interior, and then by means of a Pravaz's syringe, the
nozzle of which goes into the outer end of the catheter, injecting
ten drops of a warm solution of soda in glycerine. The mass
so softened can easily be syringed out on the following day with
warm water injected by means of a large syringe through the
inserted catheter. After removal of inflammatory secretions by
repeated syringing of the meatus, alcohol or solution of boric acid
in alcohol (1 in 20) should be dropped in the ear. Granulations
should be removed by applying Liq. ferri. muriat. or burning with
the galvano-cautery.

The indications for the surgical removal of exostoses are the
following : 1. Extreme deafness, in consequence of complete closure
of the meatus by the exostosis if there is at the same time deafness
in the other ear. 2. Suppuration of the middle ear, the escape of
the pus from which is prevented by the tumour. In such cases
speedy action is the more urgent the more marked the symptoms
of retention of pus.*

Of the methods of operation recommended for the removal of
exostosis, that by means of the gouge and hammer has proved the
best. This has the advantage of quickly removing the new-forma-
tion ; it requires great caution, however, in deeply-seated exostoses,
on account of the possible danger of injuring deeper parts by the
slipping of the instrument (Field). This method is particularly
suited for those pedunculated exostoses which are removed from
their base by two or three short blows with the hammer. Accord-
ing to Knapp the operation is made easier, if instead of directing
the chisel directly against the base of the exostosis a thin lamella
of the meatus wall underneath it is removed at the same time.

* Knapp {Z.f, 0., Bd. XIII. ) described an interesting case of successful operation
on an ivory exostosis.

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TBEATMENT.

216

The length and breadth of the chisel used varies according to the
position of the growth and the breadth of the base upon which the
exostosis is situated. I use gouges of 2, 3, 4, 6 mm. in breadth,
with more or less pronounced excavation. Chisels with handles
placed at an angle are not so safe as the straight. In four cases
operated upon by me, after covering the wound surface with iodo-
form, healing took place within a few days ; in exostoses with broad
bases, profuse suppuration has occurred. In one case where, during
a chronic middle ear suppuration with formation of polypi, an
exostosis grew from the posterior wall of the osseous meatus,
healing was brought about by the long use of alcohol after the
removal with the chisel. In deeply situated exostoses Schwartze
proposed to separate the auricle and cartilaginous meatus from
behind forwards in order to facilitate their removal, and according
to his observation with ordinary antiseptic precautions the auricle
united by primary healing, and only a slight reaction followed the
chiselling of the exostosis. Favourable results from chiselling
have been reported by Aldinger, Cassells, Heinecke, Schwartze,
Lucae, Stone, Heimann, and others.

Of other methods of operation to be described : perforation of the exostosis
by means of files (Bonnafont), drills, and dentists' drill-machines (Mathewson,
Ch. Delstanche, Bremer). This procedure is much less sure, as the perfora-
tion very often closes notwithstanding the insertion of ivory or lead pins. The
breaking off with a finely constructed pincers (J. P. Cassells, Jaquemart) is
only practicable when the exostosis is pedunculated, and is situated near the
external opening of the meatus. Even here the removal with chisel and
hanmier is preferable. Destruction of the exostosis by the galvano-cautery,
recommended by Voltolini and Delstanche, is only suitable for those situated
in the outer portion of the meatus. It is very slow, but it has this advantage,
that the operation gives rise to but slight bleeding and moderate pain. Moos
has cm'ed one case by the combined use of the galvano-cautery and the
insertion of laminaria tents. For pedunculated tumomrs with contracted
base the elastic Ugature recommended by v. Dittel may be used.

Painting the new growth with tincture of iodine and lunar caustic to
produce absorption has proved useless. The internal exhibition of iodine
and mercmial preparations is only to be advised when the disease is caused
by syphilis.

Atresia of the Eternal Meatus, — Acquired atresia of the external
auditory meatus is caused : 1. By the immediate contact of the walls
of the auditory meatus deprived of their epidermis in the course of
secondary inflammation of the meatus, due to chronic suppuration
of the external and middle ear. 2. By combined caries and necrosis
of the mastoid process and of the walls of the meatus, as, after the
expulsion of one or more sequestra, the granulation tissue growing

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216 ATRESIA OF THE EXTERNAL MEATUS.

into the lumen of the meatus is changed into fibrous connective or
osseous tissue after adhesion to the walls of the meatus. In such
cases there are often contracted osseous cicatrices on the mastoid
process, besides osseous atresia of the meatus. 3. By the adhesion
of large granulations proceeding from the walls of the osseous
section and filling up its limien, the epitheliimi being afterwards
lost by long contact of the growths. Here also the connective tissue
closing the meatus becomes changed into a fibrous mass or into
bone.

In a case observed and dissected by me, the osseous meatus was filled vnih
a pigmented connective tissue mass, containing cysts, as the result of chronic
otitis externa. It was adherent to the walls of the meatus and external surface
of the membrana timpani, there being only a fissure extending to the mem-
brana tympani along the posterior wall. In a case of pedunculate polypus,
reaching to the external orifice of the ear, in which operation was not per-
mitted, I found at a later examination atresia of the meatus, caused by adhe-
sion of the polypus on every side with its walls. The necropsy of this
extremely interesting case showed a mass of connective tissue, filling the
meatus and ca\'um tympani, which from here had penetrated the vestibule,
the facial canal and the internal auditory meatus, and had entered the
cranium. In the posterior fossa of the skull were several connective-tissue
growths, varying from the size of a pea to a hazel-nut, underneath the dura-
mater and connected with the mass of connective tissue coming from the
internal meatus.

4. By traumatic lesions (Samuel Sexton), cauterization, burning
and ulceration of the walls of the meatus. Adhesion in these
cases is caused either by the contact of the exposed walls or by
the contact of the granulations rising from the surface of the tumour.
5. By a phlegmonous, periauricular inflammation extending into
the meatus, with the formation of a mass of adhesive connective
tissue in the cartilaginous portion (Ladreit de Lacharri^re).

Fibrous atresia is caused either by a membranous septimi stretched
out usually at the entrance to the ear or in the osseous section, or
by a long mass of connective tissue varying in thickness. Osseous
atresia, usually of considerable thickness, is oftenest situated in the
external section of the osseous meatus, the whole canal being seldom
filled up by the osseous masses.

The objective symptoms of atresia vary according to its seat and
extent. In the fibrous as well as in the osseous forms of atresia the
walls of the meatus run up to the adhesion without clear demarca-
tion, thereby giving the canal the appearance of a cul'de-sac. The
further the atresia extends outwards the shorter appears the canal
of the ear. This is of importance in the diagnosis of atresia. It is

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ATBE8IA OF THE EXTERNAL MEATUS. 217

only when it is limited to the innermost section of the osseous meatus
that the surface of the adherent parts may be mistaken for the
membrana tympani. The adhesion existing between the walls of
the meatus on all sides and the background, the absence of the
short process and of the handle of the malleus, and the diminished
distance from the external orifice of the ear to the inner end of the
meatus compared with that of the other side, are sufficient guides,
however, for the diagnosis of atresia.

Further, the adherent parts must be probed in order to ascertain
whether the adhesion be membranous, fibrous, or osseous. In the
last case the background is hard as bone. It is more difficult to
distinguish between a membranous septum and an extensive con-
nective-tissue adhesion, particularly when the expanded membrane
is somewhat thick and not very yielding.

In such cases the degree of hearing sometimes informs us of the
thickness of the atresia. In osseous atresia or in extensive con-
nective-tissue adhesions there is total deafness, or nearly so, as in a
case of Moos's, in which there was a bilateral osseous atresia after
periostitis produced by eczema ; in membranous closure (septum),
on the other hand, there may be a considerable hearing-distance for
speech. As, however, perception for loud speaking is partly trans-
mitted through the bones of the head, it is advisable to use an ear-
trumpet in testing the distance for speech. In osseous or extensive
connective-tissue adhesions what is spoken through the ear-trumpet
is either not heard at all or is understood with difficulty. In mem-
branous closure of slight thickness, however, even low speech can
be understood, provided that the tympanic apparatus and the laby-
rinth have undergone no great changes. When whispering is under-
stood through the ear-trumpet it is very probable that the septum
is very thin ; and this is of practical importance in so far that in
such a case one can at once have recourse to surgical treatment of
the atresia, while in cases in which speech is not understood with
the help of the ear- trumpet surgical interference is useless.

A girl twelve years of age had suffered at the age of two from left otorrhoea,
and two years later from right otorrhoea also. At the age of nine years the
discharge stopped in both ears. The examination gave as result : symme-
trical ctU'de-aac closure of both meatuses almost in the middle of the osseous
section (c/. diagrammatic sketch of the right meatus, Fig. 90). The back-
ground is yellowish-white, and somewhat yielding on being probed. Hearing-
distance right and left for the acoumeter 1 cm., for loud speech 15 cm.
Through the ear-trumpet whispering is well heard on both sides.

Supported by the results of this testing, I proceeded to divide the septiun
with the paracentesis needle. On the right ear the hearing improved 8 cm.

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218

ATRESIA OF THE EXTERNAL MEATUS.

for the acoumeter and 5 metres for speech ; on the left the septum proved to
be thicker and more resistant, and the improvement in hearing was less than
on the right. After the operation, to prevent renewed adhesion, leaden pegs*
were introduced and allowed to remain with few interruptions for several

weeks. The result was; on the right,
^ persistency of the opening by the forma-

tion of epidermis on the severed edges of
the septum and permanent improvement
in the hearing; on the left, moderate
reaction at the seat of operation and,
later, recurrence of the adhesion of the
meatus.

In cicatricial closure of the cartilaginous
meatus in the neighbourhood of the ex-
ternal orifice of the ear, especially when
of great thickness, simple incision and
the insertion of leaden pegs have proved
insufficient, and it is in such cases that
partial excision of the cicatrix is necessary
before the introduction of tents (Ladreit
pheralthickened part of the septum, de Lacharri^re, Samuel Sexton).

In a case reported by Boihholz a ten-
dinous gray pseudo-membrane, due to chronic otorrhcea, completely closed
the right meatus 8 mm. in front of the membrana tympani. By means of
a radial incision and insertion of cotton tampons permanent healing resulted,
after which there was a marked improvement in hearing and the subjective
noises disappecured.

Fig. 90.
a, Cartilaginous meatus ; b. Septum
in the osseous section ; c, rf, Peri-

V. Foreign Bodies in the Ear.

Foreign bodies in the external meatus most frequently come
under observation in the case of children, who insert into their ears
such various things as peas, beans, pieces of paper, cherry-stones,
coffee-beans, carob-stones, pebbles, glass beads, wooden balls, fruit-
stones, sealing-wax, slate-pencil, metaUic buttons, grains of shot,
and so on. In adults, foreign bodies get into the meatus mostly
by accident. According to my experience, the most common are
pieces of camphor and of garlic, which have been put into the
meatus to allay the pain of toothache or earache, and objects used
for picking the ear, especially the bone or porcelain heads of small
lead pencils, less frequently rolls of paper, tooth-picks, matches,
and ear-picks. Besides these, pellets of cotton-wool, leaves, and
pieces of branches, grains of wheat and millet, oats and barley, etc.,
sometimes get into the meatus.

* The introduction of correspondingly thick leaden tubes is preferable to that of
leaden pegs, as the wearing of the former assists the hearing.

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FOREIGN BODIES IN THE EAB.

219

Symptoms, — The symptoms which foreign bodies give rise to are
by no means so serious as was at one time thought. Experience
has taught that the consequences attributed to foreign bodies are,
with few exceptions, due to the awkward attempts made at ex-
traction by non-professional hands.

In a considerable number of cases which were examined for other disorders
of hearing, I found the greatest variety of objects in the meat\is, of which
the patient had not the lightest idea, and which must have lain in the ear
for a very long time. Once I found a slate-pencil 8 cm. long which, according
to the patient, aged seventy years, had lain there for fifty years. As the
patient found no inconvenience from it he allowed it to remain, till deafness,
caused by a ceruminal plug, forced h\m to seek medical aid. One of my
audience at a discom^e on foreign bodies informed me that twenty-two years
before a slate-pencil had been put into his ear, but had fallen out again of its
own accord; nevertheless, I found the pencil 1 cm. long in his meatus.
Similar observations have been recorded in large munbers in both the old and
new literature. Brown found in both meatuses of a boy several pebbles which
bad remained there for seven years. In a case of Lucae's a cherry-stone had
remained in the meatus forty years, in another case of Zaufal for forty-two
years. Beim removed a back-tooth from the ear which had been there for
forty years ; Maschal removed a coral bead which had remained for forty-five
years in the meatus ; Marian removed a glass bead from the ear of a peasant
which had been there since childhood.

Sometimes, however, foreign bodies not only cause violent reflex pheno-
mena in the course of the trigeminus and vagus nerves supplying the external
meatus, but also occasion long-persistent general nervous attacks which only
disappear after the extraction of the foreign body.

The literature of otology is rich in suitable examples, but only a few of the
most interesting need be given. Arnold (cited by Moos) found in a g^l that
the cause of a persistent cough with frequent vomiting was the presence of
two beans in the auditory meatuses. After these were removed she quite
recovered. In a case of Toynbee's (L c), an obstinate cough ceased after the
extraction of a sequestrmn of bone. I have observed a similar case in my
practice. Fabricius von Hilden (cited by v. Troltsch) cured a girl suffering
from epilepsy, a dry cough, anaesthesia of one half of the body, and atrophy
of the left arm, by removing a glass bead which had lain in the meatus for
eight years. Maclagan (cited by Wilde) and KUpper saw healing of epilepsy
and deafness after removal of foreign bodies from the ear.

On the whole, however, the worst consequences of foreign bodies
in the ear are due to violent attempts at extraction. In this way
not only is the meatus, and sometimes also the membrana tympani,
injured, but the body lying in the cartilaginous section is driven
into the osseous section, and either impacted at the narrowest
part of it or after rupture of the membrane forced into the tympanic
cavity.

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220 FOBEIGN BODIES IN THE EAB.

Such attempts, usually attended with severe bleeding, give rise
to traumatic otitis externa and sometimes also to purulent otitis
media accompanied by great dizziness, in consequence of which the
auditory meatus becomes so contracted by swelling and granula-
tions that the foreign body is lost to view and its removal is rendered
very difficult or altogether impossible.

In the course of such inflammations the swelling in the meatus
may recede spontaneously under suitable treatment, and the removal
of the foreign body may be rendered easier. Very often, however,
the imprisoned body maintains the inflammation and suppuration
so long that it is either spontaneously discharged or extracted.
When the lesion and inflammation are limited to the external
meatus, cure is almost always effected, even after long continuance
of the affection. But when the membrana tympani has been injured
and suppuration of the middle ear has occurred, extensive destruc-
tion of the membrane with great deafness often remains and facial
paralysis may occur (Stacke). In one of my cases there existed,
in addition, constant violent tinnitus, hypersesthesia acoustica, and
persistent headache.

That coarse attempts at extraction may also cause complications dangerous
to life by injury to the walls of the cavum tympani and labyrinth is
proved by recorded cases of fatal termination in consequence of meningitis,
abscess of the brain, and sinus-thrombosis (Weinlechner, Frankl, Wendt,
Lucae, Zaufal, Moos, Lewi, etc.).

Diagnosis, — At the examination of the meatus the first thing is
to make sure of the presence of a foreign body, as it often happens
in the case of children who say they have put something in the ear,
that nothing can be discovered. In several such cases I have foimd
the meatus injured by former coarse attempts at extraction.
Pilcher (cited by Th. Barr) and Szokalski have even observed such
blind attempts result fatally from meningitis, and especially from
erosion of the carotid ; Lucae once observed injury and caries of
the inner wall of the tympanic cavity and complete deafness.

After having ascertained the presence of a foreign body, its size,
form, consistency, and position have next to be made out. Fre-
quently a glance is sufficient to recognise the body, but very often
when it is lodged deeply or covered with effused blood or secretion
it is more difficult to judge, as children are often unable to say
what kind of body they put into the ear.

Treatment, — The method of removal of a foreign body depends
upon its seat, consistency, size, and form, and upon the state in
which the ear is found at the first examination ; that is, whether

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EXTRACTION OF FOBEIGN BODIES FBOM THE EAB. 221

no attempt has yet been made at extraction, or whether the meatus
has not akeady been injured, inflamed, and swollen by violent
attempts at removal.

The removal of foreign bodies from the ear is, with few exceptions,
very easy and simple, provided that no difficulties have been created
by previous attempts. The latter occurrence is unfortunately so
frequent that, according to my notes, scarcely 10 per cent, of the
cases come untouched to the specialist. In the majority of cases
the body has been forced inwards and impacted, with injury to the
meatus and the membrana tympani, by the anxious relatives or by
a medical man not acquainted with the subject.

The surest and best way of removing foreign bodies from the
ear is by the use of strong injections of tepid water by means of
a large English syringe, to the end of which is attached a short
india-rubber tube (Lucae), or the rubber tube rounded at the end
as proposed by me. By pushing it up to the foreign body the
strength of the injection is increased, and the body is so much
the more quickly and surely expelled. Voltolini and Hedinger
recommend for heavy bodies — for example, grains of shot — that
the injections should be made with the patient lying on his back
and the head inclined backwards, so that the body can the more
easily be washed out of the sinus of the inferior wall of the meatus.

When foreign bodies have not been disturbed by any attempts
at extraction, as unfortimately too often happens, any other method
than syringing is rarely required. Injections are contra-indicated
when the foreign body is the head of a pencil and its cavity is
directed outwards, for then by strong syringing the water would
enter the cavity and force the body inwards, and cause it to be
impacted; also, when the membrane is perforated, as then in-
jections would cause dizziness, or the water would escape by the
Eustachian tube. Of 109 cases of foreign body in the ear, Zaufal
removed 92 by syringing ; in 17, owing to previous improper manipu-
lation, instrumental means were required for removal.

Zaufal recommends injections of oil instead of water when the body is one
that would swell. But leaving out of account the slight expulsive force of
oU injections, we consider this precaution unnecessary, because, in cases in
which the body cannot be got out after several strong water injections, its
enlargement may be prevented by immediately pouring alcohol into the ear.
The instillation of oil or glycerine, as Noquet suggests, facilitates the removal
of bodies when syringing with water.

If the body is so firmly fixed in the meatus that it cannot be got out by
strong injections, it is advisable to try the agglutinative method recommended
by Loewenberg before proceeding to operative measures. This consists in
dipping the point of a medioun-sized camel-hair brush into a concentrated

Digitized by VjOOQIC

222 EXTRACTION OP FOREIGN BOi:)IES FROM THE EAR.

solution of glue and inserting it into the meatus so as to bring it into contact
with the foreign body, which has been previously dried. By the drying of the
thick fluid the brush sticks so hard to the body that it can be drawn out when
there is not too much resistance. This proceeding is very suitable for bodies
liable to swell, wooden balls and cherry-stones, but only when there is no
inflammatory secretion in the meatus, as that prevents the drying of the glue.
For pebbles freshly-prepared cement is preferable to glue. For glass or steel
beads with the opening turned outwards Lucae reconunends a flne moist
laminkria tent, to be pushed into the orifice of the bead, which may be
removed at the end of half an hour, when the tent has expanded.

Operative Methods, — As to the surgical methods employed for
removing foreign bodies from the ear when injections and the
agglutinative method have been tried vnthout effect, no rule can
be given, as they must be regulated by a number of circumstances,
which vary in each case. While the formation of the meatus, its
width, and curvature, present many individual varieties, the situa-
tion is still further modified by the size, form, consistency, and
position of the foreign body, and by the presence of already-com-
mencing inflammation, swelling, or contraction of the meatus.
The proper proceeding to be adopted in each case is determined by
a correct judgment of the circimistances, and, here more than else-
where, the success of the operation depends on the acuteness of the
surgeon.

In every case, also, in which previous attempts at extraction
have failed, the surgeon must consider well whether it would be
better to operate at once or to postpone operating till more favour-
able circumstances present themselves. If the chances are favourable,
then it is better to operate at once, especially when the meatus has
been injured by previous attempts at extraction, as in that case
the inflammation so set up may take an unfavourable course, owing
to the presence of the foreign body. Immediate operation is also
advisable in cases in which a persistent cough or other troublesome
reflex symptoms are caused by the foreign body. It is better to
wait patiently when there is no danger to be feared, or when, the
body being situated deeply and there being coincident inflammatory
contraction of the meatus, operative treatment is impossible. The
application of cold by means of Leiter's apparatus and the insuffla-
tion of boracic powder or the instillation of spirituous solution of
boracic acid are here recommended in order to allay the swelling
in the meatus ; and only when the body can be seen should further
steps be taken to remove it. In complicated cases, especially vnth.
children, it is better to operate in light narcosis.

If the body — for example, a pea, bean, a swollen carob-stone, or

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EXTBACTION OF FOBEION BODIES FBOH THE EAH.

223

a wooden ball — ^be wedged in the narrowest part of the meatus,
or seated in front or behind its isthmus, and by the great swelling
pressed on all sides immovably against the walls of the meatus,
extraction is best accomplished with a strong curved hook (Fig. 91)
or with a firm needle with its point at right angles to its long axis
(Fig. 92).

The instrument fixed on the handle is, in the case of bodies
impacted not more deeply than the commencement of the osseous
meatus, introduced so that it is pushed with its hook horizontal
between the body and the upper wall of the meatus till it gets
behind the foreign body. It is then turned so that its point is
directed towards the body. The handle is
next pressed upwards as far as possible, so
that the point of the hook may penetrate
deeply into the body in order to ensure its
removal as safely as may be. When, how-
ever, the body is situated in the inner section
of the osseous meatus it is better to insert
the hook between the anterior inferior wall
and the body, for by pushing it along the
superior wall the posterior superior part of
the membrana tympani might very easily be
injured.

Instruments like corkscrews, recommended for
the extraction of objects that may swell, are of little
use, as they generally straighten when the body is
firmly wedged.

On the other hand, especially in the presence of
traumatic inflammation, we must condemn the use
of the galvano-cautery, recommended by Voltolini,
for burning foreign bodies, as the inflammation is
increased by the combined action of the radiating
heat. According to my idea the galvano-cautery is ^^^* ^^' ^^- ^2.
only suited for such an object as an impacted

cherry-stone, in which a hole might be burned for the introduction of an
extraction-hook. Hedinger destroyed a piece of cork tightly fastened in the
meatus by means of the galvano-cautery. Howe roughened a smooth piece
of lead wedged in the isthmus by the same means, so that it could be seized
by the extraction forceps and removed.

For deeply impacted bodies liable to swell, when the membrana tympani
is perforated, strong currents of air (Hedinger) and injections through the
Eustachian tube should be tried before proceeding to surgical means. In this-
way foreign bodies have been several times washed out from the ear (Delean,
LucaeV

Digitized by VjOOQIC

224 EXTRACTION OF FOREIGN BODIES FROM THE EAR.

The procedure is very different in the case of hard foreign bodies, such as
pebbles, glass beads, slate-pencil, cherry-stones, etc. If the body is impacted
in the cartilaginous section its removal is in most cases very easUy effected,
as by the insertion of a slightly-curved or hook-shaped probe
(Burckhardt-Merian) behind the body, it is removed without any
difficulty.

Of all the instruments used for the removal of foreign bodies
I have found most useful the fenestrated curette (Fig. 98), the
scoop-shaped steel lever of Zaufal, Lister's blunt hook, Guye*8
fenestrated forceps, Tiemann's bullet-forceps, SapoHni*s needle-
shaped pointed pincers, Trautmann*s lock forceps, or the gouge
forceps. The use of common forceps must be avoided, as they
only wedge the foreign body more firmly.

The removal of hard bodies situated in the narrowest
part of the meatus, pushed behind the isthmus or into
the tympanic cavity, is exceptionally difficult. This refers
more particularly to irregular bodies, such as pebbles,
slate-pencils, glass beads, etc., which in certain positions
easily pass the narrowest part of the meatus, while on
the slightest touch the position so changes that the
largest diameter lies across the axis of the meatus.

The removal of such bodies from the deeper sections
of the meatus depends upon their size and position and
on the relative capacities of the meatus. In some cases
the extraction is very easily accomplished, as the body
can be loosened by careful manipulation and its position
changed. In the case of a boy who had six pebbles in
his ear, and in whom no previous attempts at extraction
had been made, I got all of them out very easily by
means of a slightly bent probe. In other cases again,
all attempts at extraction completely fail ; the extraction
must then be postponed till the conditions become more
favourable, or, when dangerous symptoms appear (in-
creased temperature, optic neuritis and choked disc,
Zaufal, Pra^. Med. Tr.,1891), the auricle and the posterior
wall of the cartilaginous meatus must be detached, and
even the posterior wall of the meatus chiselled away, in
order that the body may be extracted by that way.

Fig. 93. The separation of the auricle for the removal of deeply im-

prisoned bodies was recommended by Paul von ^Egina (see
Lincke, p. 586). In recent times the operation has been again revived by
surgeons and ear specialists with good results. Isreal (Berl. Med. TT., 1876)
succeeded in removing an impacted button, Moldenhaur and Bezold impacted
pebbles, Huber a ball of wood, and PoHtzer a carob-stone from the cavum

Digitized by VjOOQIC

INSECTS IN THE EAB. 225

tympani after remoying the auricle. After the separation of the posterior
wall of the meatus as deeply as possible, Moldenhauer recommends the use
of small, smooth and grooved levers, bent at an obtuse angle in various
directions, for picking out the body.

Foreign bodies are often retained in the cavum tympani without trouble.
Occasionally, however, they produce severe inflammatory results, dizziness,
and nervous headache. If in these cases it is not possible to remove the body
into the meatus by means of sounds, small levers, or injections through the
tube, nothing remains but to separate the auricle, by which means, however,
the wished-for result cannot always be obtained, as shown by experiments on
the cadaver. V. Troltsch removed a metal ball from the cavimi tympani with
Wilde's snare.

In some few cases foreign bodies also reach the tympanic cavity from the
naso-pharynx. Urbantschitsch {Berl. klin, Wochenschr.^ 1878) saw an oat-
husk, which had stuck in the throat while chewing an ear of grain, wander
through the tube into the tympanic cavity and into the external meatus.
Schalle (ibid,, 1878) communicated a case in which, during the apphcation of
the nasal douche by means of a vulcanite syringe, a piece broken off from
the latter reached the tympanic cavity and there caused acute suppuration,
and was removed by incision of the membrane.

Among foreign bodies in the ear are still to be mentioned insects
which penetrate into the auditory meatus (the house-fly, fleas,
bugs, beetles, especially the earwig, cockroaches, etc.). They often
stick in the cerumen and die in the ear, without causing any sensa-
tion. In one case I found in the softened mass of a ceruminal
plug a fly, a bug, and a beetle.

When, on the other hand, living insects reach the osseous meatus
and the membrana tympani, they often cause violent noises and
very painful sensations : headache, convulsions, and vomiting. A
miller, whose membrana tympani was for a few minutes struck by
the fore-feet of a cockroach which had become fixed in the isthmus,
affirmed that he was driven nearly mad. The insect, which was
killed by pouring in oil, was driven still deeper in by attempts at
extraction, and had to be removed in pieces by syringing. Eohrer
removed a living butterfly from the meatus, which during the
two days it remained there, produced subjective noises and pain ;
Truckenbrod removed a living cockroach from the inner half of
the osseous meatus by means of a pincette.

Insects are most rapidly killed by pouring oil into the meatus ;
the ear should then be syringed with warm water.

Although the feeling as if there were an insect moving about in
the ear sometimes depends only on irritation of the nerve in the
meatus, I would still recommend, even in all those cases in which
examination with the speculum gives a negative result, that the

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226 INSECTS IN THE EAR.

ear should be syringed. In a case in which the patient attributed
an extremely troublesome and painful sensation in the ear to the
presence of an insect, no sign of a foreign body could be discovered
on the most minute examination, but, after syringing, a gray spot
was noticed on the surface of the water, which proved to be an
exceedingly small bug. In a man who complained for a short time
of troublesome noises in the ear and gave as the cause of it that an
insect had entered the meatus, Drs. J. Pollak and Hrubesch found
in the water with which they had syringed the ear, a very small
spider, which had remained undiscovered during the examination
with the speculum.

The larv8B of the blue-bottle fly, which sometimes develop during
summer in the ears of children with neglected, offensive discharges,
must be mentioned, as they often remain for a long time in the ear
without marked symptoms, but sometimes produce delirium by the
severe pain. They adhere so firmly by their suckers, usually in
depressions of the tympanic cavity, that they can be removed
seldom by syringing, and forceps scarcely ever succeed better. Such
larvflB are most surely removed by dropping oil or glycerine mixed
with a few drops of petroleum, turpentine, or an ethereal oil into
the ear. Some minutes after the instillation the larvae leave their
hiding-place and creep out of the meatus.

The new growths, neuroses and injuries of the external ear, on account of
their frequent complication with those of the middle ear, will be described
with the general affections of the sound-conducting apparatus.

II.

THE DISEASES OF THE MIDDLE EAR.

A. The Diseases of the Membbana Ttmpani.

The pathological changes in the membrana tympani develop either
following primary disease of the membrane, or secondary to diseased
processes which extend to the membrane from the external or middle
ear. We will first give a general survey of the most important
histological changes of the membrane, and in the following division
we will chiefly discuss its primary affections, while the secondary
changes will be considered in the description of the diseases of the
external and middle ear.

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CHANGES IN EPIDEBMIC LAYEB OF THE MEMBBANA TYMPANI. 227

Survey of the Histological Changes in the Membrana Tympani.
I. Changes in the Epidermic Layer of the Membrana Tymjpani,

In acute inflammations the delicate, transparent layer of epithelium is
loosened by being saturated with and macerated by serum, becomes opaque
and non-transparent, and is sometimes raised in the form of blisters. De-
tachment of the epidermis and reproduction of the epithelial layer usually
take place shortly after the inflammation has ceased.

In chronic inflammations of the membrane an abundant growth of epithe-
lial cells very frequently occurs, not uncommonly producing an abnormal
thickening of this layer, especially secondary to chronic otitis est., chronic
eczema, and after otitis med. suppurativa (otitis desquamativa. Buck). The
detached epidermic masses consist of swollen and fatty epidermic cells, of
free fat-globules and debris, with often considerable quantities of cholesteanne
crystals and pigment.

In some rare cases the circumscribed hypertrophy and comification of the
epidermic layer takes place, or, as in a case of
mine, the formation of a pointed, homy growth
which could not be detached from the membrana
tympani. Urbantschitsch (A. /. 0., vol. x.) first
noticed, in the course of middle ear inflammation,
small pearl-shaped nodules on the membrana
tympani and external meatus containing epithelial
cells.

In a case observed by me after a middle ear
suppuration, there was on the upper half of the Fio. 94. — Globulab Pkablt
membrane (Fig. 94) eight pearly balls of a bright K^^Tt™ ^
lustre and the size of a pm-head. They proved ^ Young Man, who had
upon probing to be hard and firmly attached, had an Affbotion of the
containing cholestearine crystals and fine-celled ^^* '^* ^ Ybab.
detritus. EUpper saw a cholesteatoma 15 mm. in size situated in front of
the umbo in a phthisical patient.

Desquamation and condensation of the epidermic layer of the membrana
tympani are, as a rule, associated with great opacity of the membrane.
These opacities can be distinguished from those caused by the mucous layer,
since in the latter the handle of the malleus is distinctly visible, while it is
very indistinct in cases of slight epidermic thickening, and invisible in cases
of great thickening. As a matter of course with deposits of that kind,
anomalies in the curvature and in the extent of the visible surface of the
membrane will also be combined, and the membrane will be found to be
either flat or uneven and rough, the boundary between it and the meatus
being obliterated.

II. Changes in the Dermic Layer of the Membrana Tympani.

Hyperemia and HtBmorrhage of the Dermic Layer, — The vascular net-
work of the membrane is not visible in the normal ear, but an increased

Digitized by VjOOQIC

228 HYPBE^MIA AND H£MOBBHAGE OP THE DEBMIC LATEB.

supply of blood, due to irritation or inflammation, renders it plainly visible,
sometimes in patches, sometimes over the whole membrane. Even by
mechanical irritation of the membrane, such as a lengthened inspection with
speculum and mirror (v. Troltsch), or by irritation of the meatus with hard
bodies, great hypereemia may be produced in the normal membrane. In disease
the excessive supply of blood to the membrane is frequently combined with
hyperaemia of the lining membrane of the external meatus, more frequently
still with a similar condition in that of the tympanic cavity ; and rarely is it the
consequence of a local inflammatory irritation of the membrana tympani itself.

Hj'persemia of the membrana tympani always commences with an over-
filling of the bloodvessels of the handle of the malleus, which extend as a
red stripe along the posterior margin of the handle to the umbo, and are
generally in connection with the hyperaemic vessels of the superior wall of
the meatus. Often the handle of the hammer is so completely covered by
the bloodvessels that its locality and direction are only recognisable by the
injected vascular bundle.* If the excessive supply of blood increases, an
injection of the circular vascular wreath situated near the periphery of the
membrane will also take place, from which radiating branches extend
towards the centre of the membrane, and come into connection with the
bloodvessels of the handle of the malleus. In still more intense
hypersemia the capillary meshes of the dermic and mucous layers become
80 injected that the membrane appears imiformly light red, purple, or copper-
coloured.

Hypersemia of the handle of the malleus often occurs in certain forms of
acute or chronic inflammation of the external meatus and middle ear, also
accompanying active and passive congestive conditions of the cranial
vessels.

Ecchymoses in the membrana tympani take place either through mechanical
contact with hard bodies, or through concussion from sudden condensation
and rarefaction of air in the external meatus, farther in ruptures, in per-
sons who were hung or died from strangulation (Hoffinann, W, Med.
Presse, 1880), then in acute myringitis and acute otitis media, and in
inflammations in the course of typhus, scurvy, variola (Wendt), very often
in influenza and sometimes in paroxysms of coughing (Trautmann). They
appear on the membrane, sometimes as sharply defined, sometimes as indis-
tinct, blacMsh-brown, irregular spots, which migrate, as was first observed
by V. Troltsch, from the place of their origin toward the periphery of the
membrana tympani and from there into the external meatus. This migra-
tion is, in my opinion, connected with the eccentric growth of the mem-
brane.

Inflammation of the Dermic Lander. — The dermic layer of the membrana
tympani is frequently the seat of inflanmiation in primary as well as in
secondary myringitis. In acute superficial inflammation the exudation is
discharged below the rete Malpighii, as a clear or purulent fluid, or as a
hsemorrhagic exudate (Bing), by which the epidermic layer is raised in
blisters. Only rarely does a fibrinous exudation upon the surface of the

* Compare my BeUuchtnngsbUder des TrommeifeUSf 1865.

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INFLAMMATION OF THE DEBMIO LATEB.

229

membrana tympani take place in the form of an easily removable pseudo-
membrane. When the whole dermic layer is inflamed the interstitial tissue
is loosened by dilatation of the bloodvessels and by infiltration with serous
fluid and round cells. In such cases the increase in bulk of the much-

Fig. 95.— Section op thb Inflamed Membrana Ttmpant of a Woman, who died
FORM Puerperal Fever, during which she suffered from Otitis media acuta
without Perforation of the Membrane.

a, Epidermic layer ; 6, Dermic layer greatly loosened, and traversed by large blood-
veBsela and pus-cells ; c, Substantia propria hardly altered ; d, Layer of muooos
membrane moderately infiltrated, and irregularly swollen.

thickened membrana tympani (Fig. 96) is chiefly caused by loosening and
thickening of the dermic layer (&), while the substantia propria (c) is almost
unaltered, and the mucous layer (d) only slightly so. The surface of the
membrana tympani generally appears uneven
and glandular.

These changes in the dermic layer are capable
of complete resolution. After acute inflamma-
tion, chronic desquamation of the epithelium or
thickenings and opacities caused by new forma-
tion of connective tissue rarely remain, and
usually with simultaneous changes in the sub-
stantia propria. Excoriation and perforating
ulceration is very uncommon after acute in-
flammation.

The pathological changes of the dermic layer
in chronic inflammations are of greater im-
portance. The increase in bulk of the cutis,
accompanied by secretion, leads to uniform
thickening of the membrane, or to the formation
of granulations and papillary excrescences,

covered with a pavement epithelium (myringitis villosa, Nassilofl), or in
some rare cases to the formation of polypi (Fig. 96).

Fig. 96.— Globular, Lobu-
LATED Polypi on the Ex-
ternal Surface of the
Membrana Ttmpani of a
Girl, 19 Years of Age,
who died of Consbouttve
Meningitis.

6, Head of the hammer;
a, c, d, Polypus.

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230 CHANGES IN THE SUBSTANTIA PROPRIA.

III. Changes in the Substantia Propria,

Patholo^cal changes in the substantia propria of the membrana tympani
must generaUy be regarded as secondary alterations, produced by disease of
the dermic and mucous layers. The occurrence of primary inflammations of
the substantia propria is without doubt, it having been ascertained by the
investigations of Moos that vessels exist in that layer.

In acute inflammations of the membrana tympani the tissue of the
middle layer is loosened and degenerated, and granules, or round cells, are
deposited between the fibres. Sometimes, however, the structure is only
slightly altered*.

The tissue-changes are greater in chronic inflammations, especially in the
suppurative affections of the middle ear. In these cases a large amoxmt of
exudation is effused by the adjacent inflamed layers into the substantia
propria, which appear as irregular, yellowish patches while the secretion
lasts, but after suppuration has ceased appear as grayish-white, chalky,
sharply defined spots. Frequently, especially in adhesive processes, after
middle ear suppuration, the membrana tympani appears rigid, and several
times as thick as normal, not unlike a thin leather or cartilaginous plate, from
great hypertrophy of its dermic and of its mucous layer to a less extent.

Exudation into the substantia propria may be completely reabsorbed, but,
owing to the slight vascularity of this layer, there often remain, especiaUy in
chronic inflammations, traces of exudation which undergo calcareous meta-
morphosis. These calcareous concretions in the membrana tympani, known
to Cassebohm,* are frequently observed. They occur most conmionly in the
course of chronic suppuration in the middle ear, more rarely, as Moos first
stated, in chronic inflammations of the middle ear, imaccompanied by sup-
puration. When the thickness of the calcareous deposits is only slight, this
change is confined to the substantia propria, but when it is considerable, the
external and internal layers of the membrana tympani take part in the
process of calcification. In extreme cases of this kind, the thickness of the
membrana tympani is increased several times, the external surface of the
membrane is smooth, while the internal is uneven, and appears as if covered
with a mass of plaster of Paris. Such membranes, when touched with the
probe, are found to be non-elastic and hard, like an egg-shell. The peripheral
poi1;ion of the membrane generally remains free from calcareous deposit.

When the membrana tympani is considerably thickened, the fibres are
infiltrated with minute fat-globules and granules, here and there com-
pletely replaced, so that, in sections, the three layers can no longer be
distinguished from each other. V. Troltsch found in one case crystallized
calcareous deposits; Bauer, in the membrane of hemicephalic individuals,
found crystals of phosphate of lime. In the calcified portions a black, or
blackish-brown pigment (Toynbee) will sometimes be found, in roundish
masses or striae, or in spindle or star-shaped cells, and fat-globules are every-
where present in different proportions.

Besides the calcareous deposits, a real osseous new-formation in the

* TractatU8 qtuUuor ancUomici de aurt humana, Halae, 1734.

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CHANGES IN THE SUBSTANTIA PROPRIA.

2^1

membrana tympaui has in some rare cases been found. The occurrence of euph
osseous formations in the human membrane was first ascertained and
described''^ by me, and was afterwards confirmed by Wendt and Habermann.
In one case observed by me, I found in the calcified membrana tympani of a
young man who had died from tuberculosis, and who had suffered for some
time from discharge from the ear, a true osseous formation 0*5 mm. in size,
behind the handle of the malleus (Fig. 97).

Wendt found a cholesteatoma on the inner surface of a perforated mem-
brane as a reddish, uneven protuberance, with a golden lustre, which had
developed from the substantia propria, and, according to Wendt, from the
endothelial sheaths of its stris. Hinton saw a lamellar cholesteatoma above

V,;;^^iiafi^

^ ^'

Fio. 97.— Ossions Nbw-Fobmation in thb Mkmbrana Tympani or a Young Man

WHO DIBD OF PuLMONABT TdBKBCULOSIS.

the short process of the malleus the size of a pea. A. H. Buckf observed in
one case an interlamellar cyst in the membrana tympani.

IV. Changes in the Mucous Layer of the Membrana Tympani,

The mucous layer of the membrana tympani suffers many alterations in
the diseases of the middle ear. Hjrpersemia of the dense vascular network of
the internal layer in acute inflammations is rare, and only for a short time
unaccompanied by hypersemia of the dermic layer. Ecchymoses in the
mucous layer are less frequent than in the dermic layer, and occur more
rarely in primary, acute affections than in intercurrent, acute inflammations
during the course of chronic affections of the middle ear, and in cases of con-
cussion of the membrana tympani. They may completely disappear, or their
pigment may remain.]: Dilated, varicose, lymphatic vessels with saccular

* Compare my treatise, Zur pcUhologischen AneUomie der Trommel/tUlrSbungen
wid deren Bedeutung fur die Dtagnostik der Qeh&rkrankhtiten, Oesterr, ZtUachrift
/. pr, HeUk, 1862.

t Med. Record, vol. vii., and Roosa's Diseases of the Ear, p. 222.

t Weodt observed in patients afflicted with smallpox the (ccurrence of small
hcmatomata in the mucoas membrane of the membiana tympani.

Digitized by VjOOQIC

232 CHANGES IN THE MUCOUS LAYER OF THE MEMBRANA TYMPANI.

expansions, such as I was the first to describe, in the deeper layers of the
mucous membrane of the middle ear, I have seen in two preparations of
the membrana tympani (chronic perforating inflammation of the middle ear).

The exceedingly thin layer of connective tissue in the mucous membrane,
inseparable from the substantia propria, may become hypertrophied by pro-
hferation, growth of round cells, and new-formation of connective tissue to
such an extent that the membrane is enlarged to several times its normal
thickness. The increase of bulk of the mucous layer, especially in cases of
chronic suppuration in the middle ear, leads to adhesion of the membrane
to the inner wall of the tympanic cavity, or without adhesion to thickening
and opacity of the membrana tympani. In several preparations I found only
the fibrous framework of the mucous layer (vide p. 19) hypertrophied and
projecting in the form of a ridge above the level of the inner surface of the
membrane. In addition, and especially in perforating inflanmiations, there
may be developed in circumscribed parts, papillary excrescences, polypoid
growths, pedunculated cysts of microscopic size, and also diffused and circum-
scribed whitish or pigmented deposits, which latter undergo calcareous
metamorphosis. **

According to Schwartze,f in children with miliary tuberculosis, tubercles
in the membrana tympani appear as yellowish-red spots of the size of a pin-
head, or larger, in the intermediate zone. Seen from the tympanic cavity,
these spots, slightly convex and distinctly circumscribed, appear prominently
above the level of the mucous membrane.

Baratoux {Bulletin et Mem. de la Sociite Otolog,, t. ii., 2) observed in
a case of syphilis, besides several small gummata on the face and auricle, a
small opalescent gumma on the membrana tympani behind the malleus,
which broke down later. Kirschner saw a syphilitic ulcer on the membrana
tympani.

The anomalies in transparency and colour, the disturbances in the con-
tinuity, and the methods of healing of the perforations of the membrana
tympani and its anomalies of curvature, will be discussed in detail in the
description of the difierent forms of disease of the middle ear in which these
changes of the membrane develop.

Inflammation of the Membrana Tympani.

I. Primary Acute Inflammation of the Membrana Tympani
{Myringitis Acuta),

Acute inflammation of the membrana tympani affects this
structure in its whole extent, or in . part only. The signs of the
inflammation are generally most marked in the posterior part of
the membrane ; only rarely does the immediately adjoining portion
of the superior waJl of the meatus participate in the affection. The

* Lucae found in a case of chronic catarrh of the middle ear carbonate of lime
crystala in the thickened epidermis of the mucous layer,
t Handbuch derpalh, Anat,, v. E. Klebs, 1878.

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PRIMABY INFLAMMATION OF THE MBMBRANA TYMPANI,

288

cause of primary myringitis caimot always be discovered. That
myringitis can be produced by pathogenic microbes has been proved
by recent investigation ; occasionally it develops after the action of
cold wind upon the ear ; after cold baths and douches ; after sea-
bathing (de Rossi) and frequently in children during the course of
an acute naso - pharyngeal catarrh* The inflammation of the
membrana tympani produced by scalds, instillation of irritating
or cauterizing substances (chloroform, acids, etc.), or by mycotic
growths, are generally combined with otitis externa.
Appearance of the Membrana Tympani, — Acate myringitis com-

Fio. 98.— A Blistkb of
THE Size of a Hkmp-seed

IN FRONT OF THE UmBO.

From a Man, 24 Years
OF Age, who for 2 Days

HAD MAD AN INFLAMMA-
TION OF THE Membrana
Tympani. On the third
Day of the Disease
the Blister disap-
peared, THE dim Mem-
brana Timpani was
covered here and there
with black Ecchymotic
Spots ; on the Fourth
Day the Power of Hear-
ing. WHICH was only
slightly lessened dur-
ing THE Existence of
the Blister, was again
completely normal.

Fio. 99. — Transparent
Pearly Blister in the
Posterior Inferior
Quadrant of the Mem-
brana Tympani of a
Young Man, who had
AN Inflammation for
18 Hours. Hearing-
distance only sughtly

DECREASED. On THE NEXT

Day THE Blister had

DISAPPEARED.

Fig. 100. — Dark - rkd
hiemorrhagio blister
UPON THE Posterior
Fold of the Membrana
Tympani of a Man 60
Years of Age, who suf-
fered FROM Inflamma-
tion FOR 24 Hours. On
the THIRD Day a dry
Ecchymosis was Visible
ON THE Site of the
Blister.

mences with great hyperaemia of the external layer of the membrane,
generally followed in a very short time by effusion into its tissue.

In the slighter degrees of myringitis, situated in the superficial
strata of the dermic layer, there occurs associated with a redness
of the osseous meatus, a diffuse vascular injection covering the
handle of the malleus and a serous infiltration of this layer along
with scattered, irregular ecchymoses ; or one or more transparent
bhsters of the size of a hemp-seed, filled with serous fluid, are
formed, the lustre and transparency of which give them the appear-

Digitized by VjOOQIC

234

PBIMABY INFLAMMATION OF THE MEMBBANA TYMFANI.

ance of fine mother-of-pearl (myringitis bullosa) (Figs. 98 and 99).
The oocnrrenoe of haBmorrhagic blisters on the membrane is most
frequently seen in influenza otitis. In a case observed by me
(Fig. 100), the dark-red, oval blister was situated upon the posterior
fold of the membrane. In another case the dark-red tumour occupied
the whole posterior superior segment of the membrane.'

These blisters last only a short time as a rule, and frequently
burst a few hours after they have risen ; or they disappear again
by rapid reabsorption of their contents. In the former case, a
small quantity of watery or sanious fluid flows from the external
meatus for a short time, and the next day, at the place where

Fio. 101. —Tense, Yellowish, Fig. 102.— Blistkr and Abscess
Transparent, Lustrous Blister, on the Riqht Mkmbbana Tym-

INVOLVINO THE POSTERIOR SUPE- PANI OF A YOUNO MaN, WHO HA1>

KiOR Portion of the Mbmbrana had an Inflammation of the
Ttmpani. From a Man 21 Years Membrane for 24 Hours,
of Age, who had Mtringitis for
86 Hours. Two Days after the
first Observation the Buster

HAD disappeared WITHOUT HAVING

BURST. The Hearing -distance,

WHICH HAD been SLIGHTLY LES-
SENED, WAS AGAIN NORMAL AFTER
A SHORT TIME.

the blister was visible, the membrana tympani will be found to be
covered by a layer of cracked epidermis, pale-gray in colour, the
hypersBmia at and along the handle of the malleus will be decreased,
and small ecchymotic spots will be seen near the point where the
blister had been.

In the more severe forms of inflammation, blisters of considerable
size, and abscesses which have their seat in the deeper strata of
the dermic layer, will be formed. They occur sometimes singly and
sometimes in groups of several, and may, according to the observa-
tions of Wilde, V. Troltsch, Schwartze, Boeck (A.f, 0., vol. ii.) and
the author, either be reabsorbed or empty into the meatus.

When inspecting the membrana tympani in such cases, there
may be observed a swelling the size of a small pea, extending

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PBIMABY INFLAMMATION OF THE MEMBBANA TYMPANI. 235

over the posterior superior portion of the membrane, the appear-
ance of which depends on the character of the exudation, and
on its situation. In the case of serous exudation the swelling
(Fig. 101) is like a large transparent pearl of a yellowish lustre ;
in the case of a purulent effusion, it is like a lustrous, non-trans-
parent, yellowish-green blister; and if a more diffuse exudation
takes place in the deeper strata of the dermic layer, the latter will
be bulged forward in the form of a bluish-red lustrous tumour, or
as a tumour covered with a slightly torn and sodden epidermic
layer, which at first sight is very like a polypoid growth.

In the primary abscesses which I have observed, and also in the
case of large blisters, the posterior superior quadrant of the mem-
brana tympani was the seat of the affection ; only once did I see
small abscesses on the posterior inferior quadrant, and once on the
anterior half of the membrane. They appear as semi-globular,
pus-green, lustrous, but non-transparent tumours, or as small,
pointed, greenish prominences, with a livid, sodden, or ecchymosed
base, and a small drop of pus will ooze out on their being opened
with a needle.

The blisters and abscesses which arise in the posterior superior
portion of the field of view usually spread over a great portion of it,
so that not only the handle of the malleus, but also the anterior
portion of the membrana tympani, are over-arched and covered
by them. The short process of the malleus generally remains
visible as a white knob in front of and above the swelling, with an
intensely red, ecchymosed base, not unlike a pustule surrounded
by an areola. The simultaneous occurrence of blisters and abscesses
is rare. In one case I observed on an inflamed membrana tympani
a blister and an abscess beside each other (Fig. 102), of which the
first disappeared on the third and the latter on the fourth day after
the inflammation began.

Symptoms, — Acute myringitis, especially at its onset, is accom-
panied by violent stinging, piercing pain, radiating towards the
parietal bone and the lateral region of the neck, sometimes also by
subjective noises and pulsation. In a superficial inflanmiation, the
pain generally lasts only a short time, and ceases when the blisters
appear on the membrana tympani. If, however, exudation takes
place in the deeper layers of the membrane, and the latter is bulged
forward towards the meatus as a bluish-red swelling, or if an
abscess is formed, the pain, especially by night, will be very severe,
and will often last for several days without intermission, until the
inflammation subsides. The formation of painless acute abscesses
in primary myringitis is rare (Boeck). A feeling of fulness in the ear.

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236 PRIMARY INFLAMMATION OP THE MEMBRANA TYMPANL

of pressure and of uneasiness, is occasionally complained of, and
there is often great hypersBsthesia in regard to noises. Slight
pyrexia occurs generally in children, seldom in adults.

The functional disturbance accompanying myringitis is not pro-
portionate to the changes in the membrane. For if the hearing
is tested at the stage when the symptoms of the exudation are
most pronounced, generally only a moderate decrease in the acute-
ness of hearing for the tone of the acoumeter and for whispered
speech will be found. The power of hearing is rarely much affected
in inflammations of the membrana tympani, which by their future
progress are proved to be of a primary nature.

Course. — The course of acute myringitis confined to the mem-
brane, and causing no considerable swelling and exudation in the
middle ear, is distinguished from that of acute otitis media by the
more rapid decrease in the inflammatory phenomena, and by the
much shorter duration of the process. The complete return of these
cases to the normal occurs usually in 3 to 4 days ; protracted, fre-
quently relapsing cases are rare. The efiPused exudation is either
rapidly reabsorbed, or is discharged into the meatus by bursting of
the epidermic layer. In the latter case, the place where the blister
was situated is covered by a gray, macerated epidermic layer, the
vessels of the malleus are injected, and the base of the bhster is
sometimes ecchymosed. After the blister has burst, a slight
decrease in the power of hearing is generally observed, caused by
the inflammatory swelling, which has extended into the cavum
tympani from the membrane. Bursting of the abscess inwards
is very rare. In one case I was led to believe that this had
occurred from the rapid disappearance of the abscess with a con-
sequent rapid decrease in the hearing- distance, and from the
sudden bulging outward of the collapsed sweUing after the air
douche. The communication of the tympanum with the cavity o
the abscess was placed beyond doubt through the sharp definition
of the exudation from the inflated air.*

Diagnosis, — The diagnosis of primary myringitis is only possible
during the first days of the disease, when the appearance of the
membrana tympani is not in proportion to the degree of fimctional
disturbance, i,e., when, in spite of the striking changes on the
membrane, the hearing-distance is not noticeably decreased. A
mistake is only possible in cases of acute otitis media, in which
the inflammatory appearances on the membrana tympani are similar
to those of acute myringitis. In the otitis media acuta a copious

* Oompare my treatise, Utber Blaaenhildung und Exsudaiidcke im Trommeifelle,
W. m. W., 1872.

Digitized by VjOOQIC

TBEATMENT. 237

exudation occurs into the cavum tympani in such a short time
that this, together with the accompanying swelling of mucous
memhrane of the cavum tympani and Eustachian tuhe will affect
the hearing to a much greater degree. The diagnosis is difficult
at a later stage if the inflammatory process extends to the cavum
tympani and Eustachian tube, in which case it is not possible to
ascertain whether the inflammation began originally in the mem-
brana tympani or middle ear.

Besults, — ^The end of acute myringitis is in most cases recovery ;
only rarely does chronic inflammation and suppuration on the ex-
ternal surface of the membrane develop, which occasionally go on to
ulceration and perforation of the membrana tympani. More often
an inflammatory swelling of the lining of the middle ear follows,
which, however, subsides in a short time. After the cure of the
myringitis, slight hypersemia, radiating vascular injection, and
opacity of the membrana tympani with continuous shedding of the
epidermic layer (myringitis sicca, de Eossi), may continue for some
time longer. The persistent changes which may remain on the
membrana tympani are streaky, gray opacities, more rarely circum-
scribed calcareous spots or atrophied cicatricial-like thinnings of
the tissue of the membrane.

Treatment, — The treatment of acute inflammation of the mem-
brana tympani during the stage of reaction is paUiative, and in
the beginning of the process is not different from that of acute
inflammation of the middle ear. We therefore refer the reader,
as regards the application of local bleeding, narcotic embrocations,
and other remedies recommended for the removal of pain, to the
special section of this book. In those cases in which the formation
of a yellowish-green abscess in the membrana tympani, accompanied
by continuous violent pain, is observed, the abscess must be opened
with a lancet,* so that the pus may discharge outwards. This
operation, which is a very easy one, is advisable in the case of
abscesses of the membrana tympani, situated in its deeper layers,
because it prevents the pus from penetrating towards the tympanic
cavity. But in the case of globular blisters of a pearly-gray lustre,
transparent, and filled with serous fluid, especially if they are
observed after the pain has ceased, the artificial opening is un-
necessary, because, according to my experience, these blisters
either quickly subside, or burst spontaneously very soon after they
have risen, and discharge their contents into the external meatus.
In inflammations in the deeper layers of the membrana tympani,

- * The details of the operation of paracentesis of the membrana tympani will be
given in the section on 'Treatment of Sero-muoons Middle-ear Catarrh.'

Digitized by VjOOQIC

238 GHBONIO INFLAMMATION OF THE MBMBBANA TYMPANI.

in which the membrane appears bulged forward in the form of a
bluish-red swelling, incisions with the lancet, or with a narrow
knife like a tenotomy-knife, are advisable only in those cases in
which, on accomit of violent pain, a diminution of tension in the
infiltrated portions of the membrane is rendered necessary. In
this instance, as well as when opening abscesses, care must be
taken that not more than one half of the lancet is inserted into the
membrana tympani, because all the layers of the membrane will
be severed if the lancet penetrates more deeply, and so the in-
flammation will spread to the tympanic cavity, and suppuration
will be set up, by which the otherwise rapid cure might be post-
poned for a long time. After the incision the edges of the wound
generally close within a short time ; only rarely does a protracted
collection of pus remain on the membrane.

The use of the air douche in acute myringitis is only indicated
in those cases where a rapid decrease in the hearing-power takes
place, after the pain has disappeared, from which an additional
swelling and secretion in the middle ear may be inferred. The
method of the author is generally used and should be continued
once a day until the deafness disappears. In the rare forms of
myringitis with pustular exudation on the membrane it is sufficient
for stopping the secretion to wash out the meatus several times
with a 1 to 2 per cent, solution of Lysol, followed by the insufflation
of finely-powdered boric acid.*

II. Ohromc Inflammation of the Membrana Tympani (Myringitis

Chronica).

Etiology. — Chronic inflammation of the membrana tympani, in
which the inflammation is confined to the membrane alone, is
among the rare diseases of the ear. It occurs as the result of
primary acute myringitis, generally after an inflammation of the
whole dermic layer, which has been followed, especially in scrofulous
and cachectic people, by continued suppuration on the external
surface of the membrana Sometimes it occurs insidiously, without
previous reactive phenomena. More frequently, however, chronic
myringitis is a sequela of a previous otitis externa, after the changes
produced by the inflammation on the walls of the meatus have
disappeared. I have also seen the signs of a chronic inflammation
remain in the membrana tympani after the cessation of suppuration

* For MyringitiB crouposa, refer to the portion 'Otitis Externa Crouposa and
DiphtbeTitica'(p. 181).

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CHBONIO INFLAMMATION OF THE MEMBBANA TYMPANI.

239

in the middle ear, and after the closure of the perforation in the
membrane.

Chronic myringitis usually affects the whole surface of the
membrane ; sometimes, however, it is limited, most frequently to
the posterior superior portion, and next in frequency to the region
of Shrapnell's membrane. The last-named forms are, however,
but rarely confined to the membrane ; generally a limited portion
of the posterior or superior wall of the osseous meatus, immediately
adjoining, is involved.

The Appearance of the Membrana Tympani. — In the slighter
degrees of diffuse inflammation the membrane appears of a moist
lustre covered with secretion, and of a gray colour with faint
yellowish- white spots ; the red vascular
bundle of the handle of the malleus and
the short process can still be plainly seen
through the thin layer of secretion. In the
case of proliferation and thickening of the
epidermic layer, however, the membrane is
covered by a whitish-yellow, non-transparent
layer, which hides the malleus, and which
can only with diflficulty be detached from
its base by syringing. If in such cases
there is a great desquamation of the dermic
layer, after peeling off of the epidermis the
membrane appears intensely congested, flat-
tened, velvety, with irregular reflections of
light scattered over it ; and when the
epidermic layer is partially detached, the

congested places, deprived of their external layer, may be mistaken
for ulcers on the membrana tympani.

Chronic myringitis leads in some rare cases to the formation of
papillary excrescences {vide p. 229). They appear as light-red
papillflB the size of a pin-head, singly or in groups (Fig. 103),
or in greater numbers spread over the whole surface of the mem-
brane. In the latter cases the membrane has the appearance of
a purple raspberry with numerous dots of light sprinkled over it.
In one case an isolated growth occurred exactly at the point of
the short process ; in another, above it upon Shrapnell's membrane.
Occasionally the papillary formation extends over from the posterior
superior quadrant of the membrana tympani upon the posterior
superior wall of the osseous meatus.

Diagnosis, — The changes produced by condensation of air in the
tympanic cavity, as seen during inspection, are important in the

FiQ. 108.— Gbanttlationb

ON THB MbUBRANA TtM-

PANi OF a Youko Girl,

WHO BOFFESBD FOR 8EVK-
BAL YbABS FROM DiS-
OMAROB FROM THE EaR ;
RkMOVAL OF THB GrOWTHH

BY Touching them with
LiQ. Ferri Sesquiohlor.

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240 CHRONIC INFLAMMATION OP THE MEMBBANA TYMPANL

diagnosis of primary chronic myringitis. Upon employing the
Valsalvan experiment, or my method, the membrane plainly
becomes curved outwards, without air passing through it into the
meatus. By this means chronic myringitis is differentiated from
chronic suppurative inflammations of the middle ear accompanied
by inflammation of the membrana tympani. This fact, however,
must not be considered as pathognomonic of chronic myringitis at
the first examination, because, as we shall see later on, in chronic
perforating suppuration of the middle ear a temporary closure of
the margins of the perforation may take place. However, it should
be mentioned, that along with chronic swelling and secretion in the
middle ear without perforation of the membrane, there may exist
a chronic secretion on its external surface.

Symptoms, — Chronic myringitis either runs a quite painless course,
or is only now and then accompanied by fleeting, lancinating pains
in the ear. Subjective noises are on the whole rare, and generally
intermittent ; and equally seldom is the feeling of fulness and
pressure in the ear complained of. The most troublesome symptoms,
which are frequently the sole reason for the patient's applying for
surgical treatment, are the severe itching and the offensive smell
from the ear, caused by decomposition of the cerumen mixed with
pus.

Eesults. — The results of the inflammation, which often lasts for
years, are either complete recovery, when the secretion ceases ; or
it may terminate in a moderate thickening of the membrana
tympani with a trifling disturbance of the hearing. Earely does
it go on to the formation of superficial or perforating ulcers. Ex-
cessive thickenings of the membrane, as described by v. Troltsch
and de Bossi, I have not observed. After the secretion has ceased,
a great desquamation of the epidermic layer (myringitis desquama-
tiva, Gottstein) or incrustation on the membrana tympani some-
times goes on for a considerable time. In myringitis granulosa
suppuration is maintained by the papillee which are developed, and
a cure will result only after their spontaneous healing or after their
removal by surgical treatment.

Treatment. — ^The treatment of chronic myringitis depends on
the changes that have occurred in the membrana tympani. If
the secretion is accompanied by a slight desquamation of the
dermic layer only, the accumulation will generally be stopped by
washing out several times with an antiseptic solution (Lysol,
carbolic or resorcin solution) and following vrith the insufflation of
powdered boric acid. If no decrease of the suppuration takes
place after using the boric acid for several days, then one should

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CHRONIC INFLAMMATION OF THE MEMBRANA TYMPANI. 241

use an alcoholic solution of boric acid (1 in 20), or a solution of
carbolic acid in alcohol (1 in 30), of which 15-20 drops of the
warm solution should be dropped in the ear and left for half an
hour. When it produces severe burning it should be diluted with
one-third water.

The use of astringents as formerly practised (sulphate of zinc and sacch.
Batumi 0*2, aqua. dest. 20*0) is now only resorted to when the antiseptic
treatment fails. In specially obstinate cases the concentrated solution of
silver nitrate (nitr. argent, cryst. 0*8, aqua. dest. 10*0) has proved very ser-
viceable. After each application the solution is to be neutralized by washing
out with a salt solution. The instillation should only be repeated when the
cauterized portion has been thrown off, and three applications a week, for the
space of three or four weeks, is generally sufficient to stop the accumulation
on the membrana tympani. The desquamative forms are the most persistent.
Bepeated instillation of alcohol is less efficient than the nitrate of silver solu-
tion. Ulcerations often heal very rapidly after the insufflation of iodoform
or iodol powder, the touching of the surface of the ulcer being seldom
necessary.

If granular formations have taken plac9 on the membrana
tympani it is advisable to destroy them by means of liq. ferr.
perchlor., either by applying the remedy to the growths in small
drops by means of a probe dipped into the fluid, or by painting
them with a small hair or cotton brush. These cauterizations are
to be continued until the membrana tympani is smooth and dry.

Cauterization with chloride of iron is decidedly to be preferred
to that with nitrate of silver or chromic acid, on account of the
more rapid destruction of the growths, and because it produces
less pain. On the other hand, cauterizing with the galvano-cautery
is preferable to all other methods on account of the smaller amount
of pain it produces and the shorter time in which healing is brought
about. When applying the galvano-cautery, a simple platinum
point should be used ; the circuit must be closed only when the
point of the electrode touches the growth; each cauterization,
applied at one sitting in 6-6 different parts of the membrane, must
last only 2-3 seconds ; the electrode must be removed immediately
after every cauterization, and the hot vapours, developed in the
meatus, may be removed by blowing into it. Cocaine solutions
(2-5 per cent.) are only of use when there is long-continued pain in
the ear.

Traumatic Lesions of the Membrana Tympani,

The traumatic injuries of the membrana tympani are produced :
^1) by direct penetration of a foreign body into the membrana

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242 TRAUMATIC LESIONS OF THE MEMBBANA TYMPANI.

tympani ; (2) by the extension of a fracture of the cranial bones
to the membrane ; and (3) by a sudden condensation of air in the
external meatus or in the tympanic cavity, more rarely by a rapid
rarefaction of the external air.

(1) The direct injuries of the membrane occur for the most part
in persons who scratch the meatus with different objects on accoimt
of an unpleasant itching, and by an accidental push pierce the
membrane with the instrument employed, such as ear-picks, hair-
pins, tooth-picks, matches, pieces of straw, pencils, etc. They
may also be caused by the careless manipulation of syringes with
long, pointed nozzles, by coarse attempts at extraction of foreign
bodies, by splinters of wood flying into the meatus, or by thorns
entering the meatus while passing through a thicket. From within
a strongly retracted membrana tympani may be penetrated by a
bougie introduced into the cavum tympani.

The site, the size, and the form of these injuries are very various,
depending, according to Zaufal's experiments on the dead body
{A,f. 0., vol. viii.), on the more or less marked spiral twisting of
the meatus ; farther, on the character of the instrument, whether
its penetrating end is sharp, blunt, pointed, rigid or flexible,
smooth or rough, and also on the force with which it was intro-
duced. The rupture from direct penetration takes place more fre-
quently in the posterior than in the anterior half of the membrane.

The appearance of the membrane varies according to the extent
of the destruction, and the time at which the inspection of it is
made. Shortly after an injury with a thin, pointed instrument,
one finds openings more or less round in shape, the margins and
surroundings of which are covered with blackish-red extravasated
blood. In the case of extensive, irregular ruptures, the shape of
the gap is not recognisable, on account of the extravasated blood
covering the membrane. But when suppuration commences, and
the extravasations are removed by syringing, it is sometimes possible
to see the extent of the destruction.

At the moment of the occurrence of the injury, a loud report is
heard, and a piercing pain is felt, followed either by fainting, or
by reeling, giddiness, and great tinnitus. After several hours relief
will take place, but the numbness of the head and the subjective
noises will still continue for a considerable time. At the commence-
ment of the reactive inflanunation, the pain and the noises will
again increase in intensity, and the latter especially continue long
after the subsidence of the inflammation and the suppuration. In
a case observed by Delstanche, of a young girl who had injured
the membrana tympani with a knitting-needle two years before,

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TRAUMATIC LESIONS OF THE MEMBBANA TYMPANL 243

there was complete deafness, intolerable tinnitus, and severe attacks
of dizziness. There was an adherent cicatrix visible on the posterior
superior quadrant of the membrane.

The injuries produced by direct action are rarely cured without
inflammation and suppuration. In cases of extensive, irregular
ruptures especially, but sometimes also in cases of smaller per-
forations, a painful suppuration of the middle ear occurs, which
lasts for weeks and months, and in consequence of which inflam-
mations in the mastoid process and in the external meatus may
develop. After the subsidence of the suppuration, permanent gaps
or cicatricial formations not unfrequently remain in the mem-
brana tympani, which often adhere to the inner w&ll of the
tympanic cavity, generally causing severe permanent deafness. In
regard to the treatment to be employed here, reference must be
made to the treatment of the acute and perforating inflamma-
tions of the middle ear.

(2) In the case of ruptures of the membrane, caused by the ex-
tension of a fracture of the cranial bones, the membrane generally
presents a fissure of more or less extent stretching from the superior
or anterior wall of the meatus. The copious bleeding from the ear
which usually takes place is due to the vessels, partly of the mem-
brana tympani, and partly of the diploe of the fractured bones. In
such cases the rupture of the membrane is of less significance than
the injury to the cranium. If death does not ensue, profuse sup-
puration, proliferation of the inflamed membrana tympani, and of
the mucous membrane of the middle ear, and adhesion of the
remains of the membrana tympani to the inner wall of the tympanum
wiU take place.

(3) We will now describe ruptures of the membrana tympani,
caused by sudden condensation or rarefaction of au: in the external
meatus. These are due mostly to blows or falls upon the ear, or
to explosions in its near neighbourhood ; as, for example, the report
of a cannon (Ome Green, Bonnafont), and from intense shocks to
the membrana tympani from a stroke of lightning (Ludewig).
Euptore of the membrane is favoured by obstruction in the
Eustachian tube, which does not allow of the escape of the air
condensed in the cavum tympani; farther by atrophy, cicatricial
formation and deposits of chalk in the membrana tympani. Buptures
due to rarefaction of air in the external meatus (kiss upon the ear,
Aeronauts, therapeutic rarefaction of air) are very rare. Tears of
the cuticular or mucous layers of the membrane alone are seldom
seen. As the ruptures of the membrane, caused by a blow upon
the region of the ear, claim the interest of the practitioner from a

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244

TBAUMATIC LESIONS OP THE MEBfBBAKA TYMPANI.

forensic point of view, it seems important to discuss these first in
detail.

At the moment of the occurrence of the blow, and of the result-
ing injury, many perceive a violent report in the ear, others a great
pain. The patient is further frequently seized with staggering,
giddiness, and great tinnitus, so that he is unable to stand upright.
The latter symptoms decrease in intensity after a few hours, but
often a feeling of stupor remains for several days, and in some
oases tinnitus continues for a long time.

The objective examination of the membrana tympani is of the
greatest importance. The appearance of the membrane is so
characteristic in the first days after the injury, that we are enabled

Fig. 104.— RuPTDBi in thk
Anterior Inferior Half
OF THE Membrane of a
BoT afteu a Box on the
Ear.

Fig. 105.— Double Rup-
ture OF the Membrane
of a Woman, 30 Years
OF Age, caused by a
Fall upon the Ear ;
Appearance on the
THIRD Day after it had
taken place.

Fig. 106.— Round Rup-
ture IN the Antebioh
Superior Quadrant op
THE Membrane of a Girl,

WHICH WAS caused BT A
LARGE Box FAXLING CFQK

HER Ear.

to ascertain from it whether the perforation in the membrane is
caused by an injury or by a pathological process.

The assertion has been made that, in the case of injuries of the
membrana tympani caused by sudden condensation of air, the
rupture appears as a linear gap (Toynbee), which extends behind
or below the handle of the malleus, and the margins of which are
applied to each other, and are only forced asunder by the Yalsalvan
experiment, or in the form of the letter T, as Hubert- Valleroux
avers. According to my observations, this form seems to be a
rare one, for in the cases seen by me, the rupture presented always
a gaping grifice, or a hole, through which the inner wall of the
tympanic cavity could be plainly seen.

The situation of the rupture in the membrane is more frequent
in the posterior portion of the membrane. There is generally only
one, seldom two rupture?, in the membrane (Fig. 106). The per-
foration is generally situated midway between the handle and the

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TRAUMATIC LESIONS OF THE MEMBBANA TYMPANI. 245

tendinous ring ; only rarely does it extend from close in front of
the handle of the malleus to the tendinous ring.

The shape of the rupture may be round (Fig. 106), as if a piece
of the membrane had been punched out, but it is generally oblong,
oval, with pointed (Figs. 104 and 105) or rounded extremities, and
the longitudinal axis of the oval is parallel with the direction of
the radiating fibres. More rarely linear tears in front and behind
the handle of the malleus, which do not separate, or irregular ragged
ruptures occur. In one of my cases the bloody edges of a ragged
rupture were so much retracted towards the periphery and handle
of the hammer that a large portion of the promontory was visible.

The margins of the rupture are sharply defined, and are covered,
either in their whole extent or only here and there, with reddish-
black coagulated blood. Sometimes ecchymosed spots wiU be found
near the rupture (Fig. 106), especially at the posterior margin of the
handle, and marked congestion of the vessels along the malleus.
The inner wall of the tympanic cavity will be seen as a bone-
yellow surface of a moist lustre, without noticeable vascular injection.
• Another symptom, important in deciding whether a traumatic
rapture of the membrane has taken place, is the auscultation sound
of the air rushing through the orifice of the rupture when the
Yalsalvan method is being periormed. For while in the case
of perforations produced by diseases of the middle ear the air,
pressing through the Eustachian tube into that cavity, escapes from
the ear with a sharp, hissing noise, even when there has been great
loss of substance, the air rushes from the ear with a very broad,
deep, breathing-sound in cases of traumatic rupture of the mem-
brane, if the injury has befallen a normal ear. It will further be
observed that a much less considerable amount of exertion is
required to press afr through the tube into the middle ear in the
latter cases.

The degree of the disturbance of hearing caused by traumatic
ruptures is usually sHght. Severe deafness only occurs when,
besides the rupture, there has also been concussion of the labyrinth.
The sudden condensation of air in the external meatus may have
two different effects.

If the force of the blow is exhausted on the membrana tympani,
tearing its elastic fibres,. the labyrinth as a rule remains intact.
The power of hearing is in these cases generally but sHghtly
lessened, for speech and the acoumeter, and the tone of a tuning-
fork placed upon the vertex is locahzed in the injured ear.

If, however, the membrane remains intact, the force of the con-
densation of air produced by the blow is not exhausted at the

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246 TRAUMATIC LESIONS OP THE MEMBBANA TYMPANI.

membrana tympani, but causes a concussion and paralysis of the
expansion of the auditory nerve in the labyrinth, by suddenly pro-
pelling the ossicular chain inwards. In these very unfavourable
prognostic cases (according to my observation with positive Einne),
the tone of the tuning-fork from the vertex is almost always localized
in the normal ear.

The course of ruptures of the membrana tympani, not com-
plicated with concussion of the labyrinth, is, as a rule, a favourable
one, as the gaping orifice in the membrane is closed again without
any marked phenomena. The cicatrization of the rupture often
takes place from the mucous membrane, as is shown by the examina-
tion. A grayish-yellow pellicle is pushed from within outward,
which may be seen for a long time, while the torn edges of the
cutis remain separated. It is only rarely that a diminution of the
rupture takes place from an equal growth of the epidermis
(Eummler), or by simultaneous growth of all the layers of the
membrane.

The coagulated blood adhering to the margins of the rupture
either falls off or migrates from the centre towards the periphery
of the membrane, and is pushed into the osseous meatus. It is
only after several weeks that the membrana tympani presents its
normal appearance; only rarely a thin cicatrix remains on the
ruptured spot.

A rare consequence of traumatic ruptures of the membrana
tympani is the development of inflammation of the membrane
and of the lining membrane of the middle ear with suppuration
(Hassenstein). The cause of this inflammation is generally from
instillation of irritating oils or other medicated solutions. The
result of such consecutive suppuration is rarely complete healing.
More often it goes on to destruction of the tissue of the membrane,
to the formation of granulations on the membrane and in the
cavum tympani, to adhesions between the membrana tympani and
the promontory (Burnett), and to covering of the edges of the per-
foration with epidermis, leaving a persistent opening (Roosa).

In most cases, disturbances of hearing caused by traxmiatic
ruptures disappear completely, so that the function becomes normal
again. It is only in those cases in which permanent changes in the
middle ear are developed in consequence of suppuration having
taken place, or in which the rupture of the membrane is combined
with concussion of the labyrinth, that disturbances of hearing of
diflerent degrees, headache and tinnitus, remain. In those cases
also in which by a blow upon the region of the ear, a concussion
of the labyrinth has been produced, without an injury to the

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TRAUB£ATIC LESIONS OP THE MEMBRANA TYMPANI. 247

membrane, and associated with tinnitus and hardness of hearing,
the function of hearing may again become quite normal after sevei&al
dajTS or weeks; more frequently, however, a disturbance in the
hearing will remain for life.

In the treatment of ruptures of the membrane I consider it best
to avoid all local applications, as by instillations of medicated
solutions, syringing or the air douche, the cure is not only not
promoted, but even retarded. But when in the open air, especially
during damp and cold weather, the patient must close the meatus
with cotton wool to protect the exposed mucous lining of the
tympanic cavity from atmospheric influences. In cases of con-
cussion of the labyrinth the application of a constant electric current
causes an improvement in the hearing-distance and a decrease of the
subjective noises.

The Traumatic Btt^ture$ of the Memhra/na Tympcmi from a Forensic
povnt of view,—Ii a surgeon is asked to state whether a rupture is of a
traumatic nature, it is necessary above all that the patient be examined
during the first few days after the injury has taken place ; for if the examina-
tion take place only a considerable time after the infliction of the injury, the
surgeon, owing to cicatrization of the rupture, may not be able to ascertain
whether rupture has taken place at all, and whether the existing functional
disturbance has really been produced by an injury.

A medical jurist cannot say that a case is of tramnatic origin if at the
time of his first examination a suppurative inflammatory process has already
taken place in the membrana tympani and in the middle ear, as the appear-
ance of the membrane in such a case is not distinguishable from that in
a primary suppurative process of the middle ear. He will therefore be justi-
fied in concluding a rupture of the membrane to be traumatic only if, after
having discovered the almost characteristic appearance of the membrana
tympani above described, cicatrization of the rupture take place in the space
of several weeks under his observation. The latter is of special importance,
because a persistent gap, produced by a previous purulent process, may be
present, and might be mistaken, on account of the sharp definitions of its
margins and of the other appearance of the membrane, for a traumatic
rapture. Such a mistake will not, however, occur if the surgeon bear ia
mind that a gap caused by a previous suppuration, as soon as its margins are
healed over, will not be closed at all. Tramnatic ruptures, however, according
to my observations, have only two results : either cicatrization takes place
during the first weeks or suppurative inflammation occurs.

If the traiunatio nature of the aflection of the membrana tympani has been
ascertained by the surgeon, another question will have to be answered, viz.,
whether the injury is to be considered as slight or severe.

An injury of the membrana tympani is to be called a slight one if it is not
complicated with concussion of the labyrinth, and if, after cicatrization of the
rupture, apart from the duration of the process of cicatrization, the function
of hefiuring retinms to its normal state.

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248 TRAUMATIC LESIONS OP THE MEMBBANA TYMPANI.

An injury of the membrana tympani must, however, be considered as
severe if by a blow upon the ear concussion of the labyrinth has taken place.
For the diagnosis of paralysis of the auditory nerve the general result of
testing of hearing should be taken into consideration, especially great deaf-
ness for the acoTuneter, watch, and speech, the lateralization of the tone of
the tuning-fork in the non-afifected ear when placed on the vertex and positive
Binne. It should be specially understood that the results of testing should
only be used by the medical jurist for judgment when repeated examinations
have been made, so as to completely exclude simulation (vide the section on
* Simulation *).

An injury of the membrana tympani will also be a severe one if, a traumatic
rupture having been ascertained, it is aggravated by suppuration; and
changes in the middle ear (adhesions, granulations) are produced by it which
cause a permanent disturbance in the hearing.

This will show that the medical jurist is not always able on his first
examination to form a judgment as to the character of an injury, but that in
a nvunber of cases a lengthened observation, extending over at least three
months, is required ; for concussion of the labyrinth may exist after an injury
of the ear, the consequences of which will not permanently remain, as the
function of hearing sometimes becomes normal a,gain after two or three
months. In the same manner a suppurative process, which aggravates a
ruptiu*e of the membrane, may end without leaving any changes in the
middle ear.

In the case of functional disturbances, produced by a blow upon the region
of the ear, and caused by concussion of the labyrinth without any injury to
the membrana tympani, the surgeon cannot form an opinion as to whether, in
a given case, the disturbance of hearing was caused by an injury or not, as
the objective appearance of the membrana tympani and other characteristic
indications are wanting as data. The surgeon must therefore in such cases
always bear in mind the possibility of the existence of a chronic affection of
the labyrinth or of the middle ear, which the alleged injured person may
make use of to sue his opponent after a quarrel. If, however, the surgeon
finds, shortly after the alleged injury is supposed to have taken place, calcifi-
cation and cicatricial formations on the membrana tympani, he may conclude
with certainty that it is a chronic process in the middle car, because changes
of this kind cannot develop in a few days, but require a considerable time.

Paragraph 156 of the Austrian Penal Code, which enumerates the per-
manent consequences of injuries, the presence of which entails the highest
measure of punishment (hard labour for five to ten years), includes the loss
or the lasting defect of the hearing-power among * aggravating circumstances.*
E. Hoffmann* makes the following remarks about this : * Although it
cannot be doubted that the loss or a great disturbance of hearing on one
side causes a decrease in the power of hearing, the same importance cannot
be ascribed to such a loss as to the loss of the power of vision in one
eye. The legislator clearly thought of the sense as a whole, and in the new
(Austrian) draft, as well as in the German Penal Code, hearing in general is

• Lehrbuch dtr gretchtlichtn Medkin^ Wien, 1878.

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TRAUMATIC LESIONS OF THE MEMBBANA TYMPANI. 249

only Bpoken of, but no difference is made between the hearing in one or both
ears, as was done regarding the power of vision. We must also bear in mind
that it is only a considerable disturbance of hearing, which may be set down
as a defect of the hearing in the sense of the law, and it is advisable,
just as in the case of weakness of vision, that we should confine ourselves in
doubtful cases only to the explanation of the nature and of the degree of the
functional disturbance, and leave it to the judge and to the jury to say
whether after such an explanation they will recognise the case as coming
under clause a of paragraph 156 or not.' To this argument I should like to
add the remark that although the loss of hearing on one side causes no
notable disturbance of hearing in ordinary intercourse, the fact should not
be lost sight of, that according to experience, in cases of one-sided deafness^
the sound ear becomes very frequently sympathetically affected, and that
such an affection, as a rule, causes a rapidly increasing hardness of hearing.

In conclusion we will draw attention to the ruptures of the membrana
tympani observed in those whose death was caused by hanging. According
to the cases communicated by Wilde, Ogston, and Littr^, ruptures seem
more frequent in those who have been executed than in suicides. How the
rupture occurs is not very clear, and I am myself in doubt about this matter.
The fact that in the cases described by Ogston and Schwartze the torn patch
of the membrane was turned outwards, would show that the mechanical
force (excessive condensation of air) must have acted from the direction of
the tympanic cavity.

According to the observations of Brigade Surgeon Chimani, during ten
years (1867 to 1877) among 6,041 aural patients treated, 54 cases of rupture
of the membrana tympani were observed. They were caused in 38 cases by
boxes on the ear, in 6 cases by falls upon the head, in 8 cases by a kick from
a horse on the head, in 2 cases by strokes upon the head with wooden clubs,
in 2 cases by the playing of brass instruments (signal trumpet and helicon),
in 2 cases by the report of a loaded gun in the immediate neighbourhood
of the ear, and in 1 case by a fall into the water from a considerable height.

The ruptures caused by boxes on the ear were in 86 cases in the left and
only twice in the right ear ; the rupture was in 27 cases in the posterior
inferior quadrant of the membrana tympani, in 9 cases in front of and
somewhat below the extremity of the handle of the malleus, and twice in the
superior posterior portion of the membrane, almost on a level with the short
process. The rupture was never linear in form, but was generally ragged,
roundish or oval. The bleeding was in no case so considerable as to be per-
ceived by the patient. During the first days giddiness, tinnitus, and con-
siderable functional disturbance generally took place. In 84 cases perfect
recovery without any functional disturbance resulted ; in 4 cases no complete
cure was effected; indeed, in 2 of them, in which the patients had been
repeatedly subjected to blows on the ear when the rupture already existed,
and which came imder treatment only on the 8th and 14th days respectively
after the occurrence, a purulent inflammation of the middle ear, with perfora-
tion of the membrane and a superficial necrosis on the mastoid process, set
in. The perforation extended over the posterior inferior and central portions,
and could not be made to close by treatment.

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250 THE DISEASES OF THE CAVUM TYMPANI.

The ruptures caused by falling upon the head were 4 tunes m the anterior
inferior quadrant, once in the centre of the posterior portion of the mem*
brana tympani, and once in the region of the short process of the malleus.
The bleeding was in 3 cases so considerable that the patients had their atten-
tion drawn to the injury of the ear by the blood flowing from it. In 2 cases,
in spite of the perforation being healed, a considerable hardness of hear-
ing, and in one case a labyrinthine affection, remained.

The ruptures produced by the kick of a horse on the hecul were all in the
right ear and the posterior inferior quadrant (flap-wounds); one case was
accompanied by extravasation of blood on the membrane and on the lining
membrane of the meatus. In all cases recovery without any functional dis-
turbance took place after suppuration had ceased.

In the same manner the ruptures caused by blows upon the head, and by
the report of a loaded gun, ended in ciure by suppuration. In the one case in
which the rupture of the membrane was produced by a fall into water from
a considerable height (attempted suicide), the membrana tympani was torn
in its whole extent. The injury, which healed up after a lengthened suppura-
tion, left behind considerable functional disturbance.

The fact that formerly ruptures of the membrane frequently occurred in
artillerymen, while they are now scarcely met with at all, may be explained
by the fact that since the introduction of breechloaders the serving party
withdraws a distance of about twelve paces, with the exception of one man
who attends to the firing, but also from a considerable distance, by which
means they are protected from the action of the most intense sound.

B. The Diseases op the Cavum Tympani, the Eustachian Tube
AND the Mastoid Process.

General Observations.

The pathologioo-anatomioal examination of the ear in the last
ten years has given very important results. In the larger number
of the cases of ear disease, the disturbance of function was foimd to
have its seat in the middle ear, and the primary diseases of the
auditory nerve apparatus are found to be much more rare. Among
the diseases of the ear, the affections of the middle ear have for this
reason the most interest for the practitioner.

The principal seat of the diseases of the middle ear is in its
membranous lining. From here the inflammatory changes start,
which not only often disturb the hearing, but also may extend to the
neighbouring organs and menace the life of the patient.

The knowledge of these changes is therefore of great importance,
as they form the basis for the diagnosis and treatment of middle-ear
affections.

The inflammatory processes and their results on the lining of the
middle ear show in general the character of inflammation of the

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THE DISEASES OF THE CAVUM TYMPANI. • 251

maoons membranes of other organs with this difference, that in the
middle ear thickening of the tissues and adhesions of the diseased
snrfaces of the mucous membrane occur more frequently than in
other organs. We find, therefore, in inflanmiations of the lining of
the middle ear the changes which occur in other inflamed mucous
membranes, as hypersemia and serous infiltration, loosening and
excessive swelling through exudation and infiltration of round cells ;
farther, the secretion of free exudate from the surface of the diseased
mucous membrane, in the form of serous, mucous, or pustular
secretion; and lastly as secondary diseased products, organized
connective tissue, which, in the course of inflammatory processes,
occurs as thickening and proliferation of the mucous membrane, or
strings of connective tissue in the middle ear.

The inflammatory processes in the middle ear show great varia-
tion, as well anatomically as from the clinical point of view. Their
course is either acute, sub-acute or chronic, and they may heal with
complete restoration of the normal hearing, or, by the production of
permanent diseased products, may produce deafness to a varying
degree.

It has been tried to gather the different forms of disease of the middle ear
into definite classes, sometimes the etiological factors, sometimes the patho*
logico-anatomical conditions have been used as the basis for the classifica-
tion. These classifications have proved mipractical, as, on the one side,
analogous processes are produced by different causes, and on the other, with
similar anatomical changes, the clinical aspect of the middle-ear infiamma-
tion may be quite different. In a similar way the anatomical examination,
as well as clinical observation, contradict the views which have been
advanced, that the different forms of the middle-ear inflammation are only
successive steps in one inflammatory process. For while one form of inflam-
mation may change into another, and show the different steps of develop-
ment, it is positively proved clinically that certain inflammatory processes of
the middle ear show a peculiarity in their beginning and entire course which
gives them their typical character. These peculiarities are of great impor-
tance from the clinical aspect, as will be seen in the special descriptions
of middle-ear affections, for, in many oases, through these alone the exact
prognosis and the proper method of treatment can be determined.

From what has already been said, it will be seen that, according to
the present state of our knowledge, a classification on a clinical basis
seems to be the best. The description according to clinical types not
only facilitates the survey of the many forms of inflammation, but
also serves as a guide in every single case, as it supplies the practi-
tioner with indications for diagnosis, prognosis, and treatment.

If we consider the inflammations of the middle ear in a general
way, according to their leading clinical features, we meet in the first

Digitized by VjOOQIC

262 * THE DISEASES OF THE CAVUM TTMPANI.

instance principally with a great groap called catarrhs of the middle
ear, in which the inflammation, accompanied by hyperaemia and
swelling of the mucous membrane, is characterized by the discharge
of a serous, or of a tough, colloid mucous secretion. This form of
inflammation of the mucous membrane generally runs its course
without notable phenomena or lesion of the membrana tympani,
and may either completely subside, or it may give rise to various
changes, such as adhesions between the ossicula and the walls of
the tympanic cavity, with permanent hearing disturbances taking
place during its course, in consequence of the growth of connective
tissue in the mucous membrane, and of the formation of bands
of tissue.

Next in order to these adhesive processes following middle-ear
catarrh, is a kindred inflammatory form, cHnically different, how-
ever, in many respects, in which, without any demonstrable secre-
tion, the ossicula, but most frequently the stapes, become fixed,
owing to the gradual shrinking and induration of the mucous mem-
brane (sclerosis) and of the ligamentous apparatus. I refer here
to those insidious forms producing severe deafness which so fre-
quently come under observation, the so-called ' dry catarrh.' They
will be more fully described in the special portion.

Another group of inflanunations. of the middle ear includes
those forms which develop with acute inflanunatory phenomena,
more or less violent and sudden effusion of a purulent or
muco-purulent exudation, in which, as a rule, the membrana
tympani is also affected by the inflammatory process. If we take
a general survey of this group, we may say that the course of the
affections comprised in it is such that either the inflammation
quickly reaches its climax, and the whole process subsides after a
short period without lesion of the membrana tympani (acute
inflammation of the middle ear), or in still more severe forms
perforation of the membrana tympani, with effusion of purulent or
muco-purulent secretion (acute perforating or suppurative inflam-
mation of the middle ear), takes place, in consequence of a copious
effusion with ulceration of the membrana tympani. The latter form
of inflammation may also subside after a short time with cicatriza-
tion of the perforation and restoration of hearing, or it may lead to
chronic suppuration of the middle ear (chronic perforating or suppu-
rative inflammation of the middle ear). This may also subside,
but frequently causes permanent disturbances of hearing in con-
sequence of ulceration of the membrana tympani, exfoliation of the
ossicula, granulation and shrinking of the mucous membrane, with
anchylosis of the ossicula ; or it may even have a fatal issue by

Digitized by VjOOQIC

CATABRH OF THE MIDDLE EAB. 253

extension of the suppuration to the cranial cavity and to the adjoin-
ing sinuses.

In consideration that the greater proportion of cases of disease extend over
the whole of the cavum tympani and the Eustachian tube, and that diseases
limited to the Eustachian tube are very rare, I consider it better for the
general study of middle-ear diseases to describe them together than to
separate them, as is done in other text-books.

These general observations should be noticed by the reader in order to
understand the way in which middle-ear affections are described in this book.
If this differs relatively from the forms generally used in otology, it is in the
effort to limit certain forms of middle-ear inflammation more sharply in
their clinical and practical significance.

As the terms * catarrh ' and * inflammation of the mucous membrane * are
synonymous, names like ' purulent catarrh of the middle ear,* or ' purulent
inflammation of the middle ear,* can be used for the same purpose. For
practical purposes, however, it would be advisable to call those forms which
run their course without significant inflammatory phenomena, and with a
discharge of sero-mucous exudation, ^ catarrhs,' and those forms which are
accompanied by violent inflammatory phenomena, by formation of muco-
purulent or simply purulent secretion, * inflammations.* Certain designations,
as otitis media serosa, hsemorrhagica, crouposa, diphtheritica, etc., are in so
far justifiable, as they indicate in a certain case some pecuHarity of the
process, a more distinct clinical definition of the disease being intended
by it.

1. GaTABBH of THE MiDDLE EaB

{Otitis Media Catarrhalis).

The inflammatory affections of the middle ear, which are clinically
comprised in the appellation ' catarrhs of the middle ear,' are
characterized anatomically by more or less pronounced hypersemia,
swelling and desquamation of the mucous membrane of the
middle ear, and by the secretion of a clear, serous fluid, or of a
viscid, sticky, mucous exudation into that cavity. They mostly run
their course without marked active symptoms, and without dis-
turbance of the continuity of the membrana tympani, and end in a
cure by subsidence of the changes, or in the development of per-
manent inflammatory products, which lead to rigidity of the articu-
lations of the ossicula, to abnormal adhesions, and to their fixation
with permanent disturbance of hearing. From a practical point of
view, especially in regard to the difference in the modes of treatment,
I have considered it best to describe first the catarrhs which are
accompanied by demonstrable secretion and swelling, and then those
adhesive .processes which either develop independently or as a
sequel to the catarrhs with exudation.

Digitized by VjOOQIC

254 THE BECBBTING FORM OP MIDDLE-BAB CATABBH.

(a) The Secreting form of Middle-ear Catarrh.

{Syn. : Sero-mucous Middle-ear Catarrh, — Otitis Media Serosa, —

Catarrh of the Cavum Tympani and Eustachian Tube.)

Etiology. — The causes of the cataxrhs of the middle ear with dis-
charge of serous or mucous exudation are atmospheric influences,
colds, influenza, the acute exanthemata and syphilis ; but most fre-
quently they are due to the extension of acute or chronic catarrhs
from the naso-pharynx. The knowledge of the presence of pathogenic
micro-organisms in the catarrhal secretion of the cavum tympani leads
one to conclude that middle-ear catarrh often occurs through bac-
terial invasions from the naso-pharynx. Besides these, sero-mucous
exudation is produced by paralysis of the muscles of the palate and
tube, and after diphtheria, and, as I first observed, from pressure of
new growths upon the canal of the tube. The exudation into the
cavum tympani is caused in the first instance by the inflammatory
process in mucous membrane, but the secretion of serous fluid is
often produced by the rarefaction of air in the cavum tympani due
to closure of the tube.

In the sero-mucous catarrhs the affection generally extends over
the whole surface of the middle ear, yet in recent catarrhs which
extend from the naso-pharynx, the swelling and hypersecretion may
be limited to the lower portion of the Eustachian tube without ex-
tending to the cavum tympani. It is these cases which occur in
the course of acute or chronic naso-pharyngeal catarrh. They are
rarely primary, and are combined with an intumescence and hyper-
secretion of the ost. pharyng. tubae, and may extend some distance
into the canal of the tube. These pecuhar catarrhs of the tube may
heal without any disturbance of hearing, remaining as a local disease
of the Eustachian canal, or they may extend to the cavum tympani
and form the source of adhesive processes which cannot be cured.

In the affections, however, which are accompanied by great hard-
ness of hearing, impermeability of the Eustachian tube and a great
concavity of the membrana tympani, and which are generally called
* chronic catarrhs of the tube,* especially common in childhood, the
disease is by no means confined to that portion of the tube, but is
as a rule spread over the whole mucous membrane of the middle
ear. The so-called chronic catarrhs of the tube, therefore, can only
rarely be separated from the chronic catarrhs of the middle ear, wid
this term should only be employed, if in a given case the symptoms
denote localized swelling and impermeability of the tube.

Appearance of the MemArana Tympani,— The appearance of the
membrana tympani in the sero-mucous catarrhs of the middle ear

Digitized by VjOOQIC

THE BECBETING FORM OF MIDDLE-EAB CATABBH.

255

presents many varieties, which depend partly on the duration of
the a£fection, partly on the transparency of the membrane, on the
quantity, character, and colour of the exudation, and on the amount
of blood-supply in the mucous membrane of the tympanic cavity.

When the membrana tympani is transparent, the accimiulation
of serous or mucous exudation in the tympanic cavity, as I first
observed and described,* can be distinguished by a peculiar appear-
ance of the membrane. For the fluid can be seen through the
membrane in the dependent portions of the tympanic cavity, its
level ^ being sharply defined from the air -filled portion of the
tympantun by a line on the membrane.

The Une of demarcation, which is sometimes dark-gray or black,

Fig. 107.— Accumulation
OF Fluid Effusion in
THB Inferior Portion
OF theTtmpanic Cavity,
wATucgn BT A Bright
Linb.

In a joxxng man during
the oouFM of a aevere
cold in the head. Cured
by Politzerization.

Fig. 108.— Accumulation
OF Effusion in the
Inferior Portion of
THE TrMPANio Cavity.

The line of the fluid level
is curved and wavy. In
a woman 40 years of age
and syphilitic. Removal
of exudation by para-
centesis.

Fig. 109. —Change of
Position of the Line
of the Fluid Level of
THE Exudation by In-
clining the Head back-
wards.

In the same woman as
Fig. 108.

like a hair stretched across the membrane, sometimes shining
white (Fig. 107), extends either concave, convex, or wavy (Fig. 108),
or the fluid may be bounded by two lines, which, commencing at
the inferior extremity of the handle of the malleus, diverge down-
wards with a slight curvature (Fig. 110). Frequently the line of
fluid level is visible only in front of the handle (Fig. Ill), or only
behind it, or it may be that it is seen only under a certain light
as a number of irregular lines, which change their position or
disappear altogether after a short time. The colour of the mem-
brana tympani below the level of the fluid is dark and yellowish,
above this line much lighter and gray. In general the yellowish
colour of the exudate shining through the membrane is more pro-

• Diagnose und Therapie der Anaammlung aerd'ser FlvMigkeit in der Trwnmel'
h'ihie, W. med, Wochtnndir,, 1867 ; Ueber bewegliche exnidcUe in der Trommel-
hihU. W. med. Pre9$e, 1869.

Digitized by VjOOQIC

256

THE SEGRETING FORM OF MIDDLE-EAR CATARRH.

nounced when it is serous or syrupy than when it is a viscid
mucus.

If such lines can be observed on the membrana tympani, the
diagnosis of accumulation of secretion is materially supported by
the change in the position of the line, if the head is inclined either
forwards or backwards. Especially when the secretion is liquid,
the change in the position of the line will be very rapid, as the
fluid, when the position of the head is changed, flows towards the
deepest portions of the tympanic ca\'ity (Fig. 109). If the exuda
tion is tough and mucous the line as a rule changes its position
either very slowly or not at all.

If the level of the exudation reaches the superior portion of the
tympanic cavity, the line of demarcation will be wanting, because

Fig. 110. — AcouMULATioN of a Suoht
Quantity of Exudation in the In-

FEBIOB PoBTION OF THE TyMFANIO

Cavity.
The level of the exadation is bounded
by two lines meeting at the handle of
the malleus. In a man with an acute
catarrh of the naso-pharynx. Cure in
three days after the application of my
method.

Fig. 111. — Accumulation of a Con-
bidkrable quantity of exudation.

The line of the fluid level is only visible
in front of the handle of the malleus.
In a man with a chronic catarrh of the
naso-phar}'nx. Removal of the exuda-
tion by paracentesis of the membrana
tympani.

in that case the fluid covers the whole inner surface of the mem-
brana tympani, and the exudation can only be distinguished by
the peculiar deep yellowish, greenish - yellow or reddish - yellow
colour of the membrane. This reflection, which is caused by the
yellowish colour of the exudation, is most strongly pronounced
behind the umbo, in the region of the promontory, and it is so
decidedly different from the appearance of the normal membrane
that the diagnosis of accumulation of serous or mucous exudate in
the tympanic cavity may be made from it alone.

Often no line of demarcation appears until air has been forced
into the cavum tympani. In all these instances the lustre of the
membrane is greatly increased, and the handle of the malleus is
much more sharply defined than in the normal state.

Digitized by VjOOQIC

THE BECBETING FORM OF MIDDLE-EAR CATARRH.

257

The changes which are observed in the above appearances of the mem-
brana tympani inmiediately after inflation are very interesting. If the
exudation is serous, and the membrane remains transparent after the air
has entered the tympanic cavity, the froth produced by the current of air can
be plainly seen as a number of dark or lustrous well-defined rings, which
change their locality when observed for some time, and are in lively motion
when the secretion is fluid (Fig. 112). Sometimes at the anterior inferior
margin of the field of view one or more air-bubbles will be seen to enter,
which, sometimes slowly, sometimes rapidly, pass upwards out of sight.

The air-bubbles and the secretion are, however, only visible if the mem-
brana tympani retains its transparency after inflation. Frequently, however,
when the catarrh has lasted a long time the diagnosis can no longer be made

Fio. 112.— Frothy Sbcrbtion in the
Tympanic Cavity aftbb Inflation in
A Case of Accumulation of Sebous
Fluid.

In a patient with an acute catarrh of the
naao-pharynx.

Fio. 113. — Appearance of the Mem-
brana Tympani in a Catarrh of the
Eustachian Tube and of the Tym-
panic Cavity.

Great inward curvature of the membrane.
In a boy with great deafness, which
was cured by inflation after my method,
continued for several weeks.

from ocular inspection through the opaque membrane, even when large
quantities of secretion are present.

With regard to the curvature of the membrana tympani and the position
of the handle of the malleus, it will frequently be foimd, especially in recent
eases, that no noticeable deviation from the normal state exists ; but after the
catarrh has persisted for a long time, when the Eustachian tube is imper-
meable, the membrane is forced inwards by the excess of the external air-
pressure, the handle of the malleus (Fig. 118) is strongly inclined inwards and
backwards and appears shortened (v. Troltsch), while the short process and
posterior fold of the membrane project markedly outwards (Figs. 118 and 114).
The short process of the hammer appears as a prominent pointed projec-
tion, and the posterior fold as a whitish or tendinous gray, sharp ridge
which is sometimes straight and sometimes curved backwards and down-
wards, forming a sharp angle with the handle of the malleus. When the
membrana tympani is excessively retracted, the handle of the malleus may
be completely masked by the posterior half of the membrane and be quite
invisible.

The inward curvature of the membrane in this instance is rarely uniform.

Digitized by VjOOQIC

258

THE SECRETING FORM OF MIDOLE-EAB CATMUtH.

As the periphery of the membrana tympani has a greater power of resistance
than the central portion, the latter is forced inwards more strongly by the
external air-pressure, which produces, especially in the anterior inferior
quadrant, a curve which I first described as the peripheral curve of the mem-
brana tympani, and which can be distinguished by a linear, lustrous stria
visible in that situation (Fig. 113). Besides this lustrous line, a small
irregular reflection of light will also be found close in front of the inferior
extremity of the handle of the malleus. The colour of the membrane is a
dark, full-bodied gray (yellowish-gray in the case of exudation), mixed with
a violet or reddish tinge, dependent on the intensity of the redness of the
inner wall of the tympanic cavity shining through.

After a long duration of the catarrh, psurtial thinning of the membrane in
one or more places frequently takes place, rarely in the anterior half, of tener in
the posterior half. These atrophies may be present after a catarrh without

Fig. 114.— Appkabanob op the Mem- Fig. 115.— Conditign op the Membrana
BRANA Tympani op a Man 30 Years Tympani in the same Patient immb-

op Age. diately apter Inflation.

Patient suffered for two months from a
catarrh of the middle ear, with great
swelling of the mucous membrane of
the Eustachian tube, in consequence of
a cold in the head. The membrane
was concave, and its colour grayish-
violet. Cure of the great deafness by
inflation after my method for 3 weeks.

producing disturbance of hearing, but occasionally produce deafness of more or
less degree. They look like more or less sharply defined depressions, with one
or more irregular reflections of light at their lowest part, and are very similar
to the cicatrices of the membrana tympani. If the atrophied posterior portion
is thinned and forced inwards to such an extent that it comes into contact
with portions of the inner wall of the tympanic cavity, the long process of the
incus and the posterior cms of the stapes will be seen behind the handle of the
malleus as a bony yellow, angular, curved protuberance (Fig. 116). And if
the membrane is also in contact with the promontory, the latter will be dis-
tinguished as a projection with a yellowish lustre behind the umbo, behind
which the niche of the fenestra rotunda will be seen as a depression.

The membrana tympani, forced inwards in consequence of the imperme-
ability of the Eustachian tube, presents only slight movement when examined
by means of a pneumatic speculum. As soon, however, as the tube is made
permeable by the application of my method or by catheterization, amobiUty of

Digitized by VjOOQIC

THE SECBETIKG FORM OF MIODLE-EAB CATARBH.

259

(he membrane much greater than in the normal state will be observed during
the examination with Siegle*8 speculum. Occasionally the presence of secre-
tion in the middle ear may be ascertained by its being set in motion with this
instrument.

If the membrane is curved inwards a remarkable change takes place in its
appearance immediately after inflation. The handle of the malleus (Fig. 114)
retiuns nearly to its normal position (Fig. 115), its vessels generally become
gi'eatly injected,* the short process of the malleus is much less prominent,
and the marked posterior fold of the membrane becomes almost completely
obUterated. In consequence of the great bulging out of the expanded mem-
brane, the handle of the malleus lies almost invisible in a depressed groove of
the pale membrane, which has become non-transparent (Fig. 115). Partial

I'iG. 116. — Apprarancb of

THB MeMBRANA TtMPANI

IN A YouNQ Man, 17
Ykars or Age, who

SUPFBRED FOR 8 YeaRS

PBOM Chronic Catarrh

OF THE MmOLE EaR.

Xaso-pharyngeal catarrh,
with great swelliDg of
the mucous membrane of
the Eustachian tube.
Hearing- distance almost
normal after one inflation
by my method.

Fig. 117.— Condition of

THE MEliBRANB IN THE

SAME Patient iiimedi-

ATELT AKTER INFLATION.

Fig. 118. — Hemispherical
bulging of the pos-
TERIOR Superior Por-
tion OF THE MbIIBRANA

Tympani by Yellowisu
Exudation.
In a man who contracted a
catarrhal discharge in the
middle ear during a cold
in the head, with slight
inflammatory symptomn.
Cure in two weeks with
air- douche.

thinnings of the membrana tympani curve outwards in a bubble -like form
(v. Troltsch), and not imfrequently the exudation, forced into them from the
tympanic cavity, can be observed of a yellowish colour shining through. If
the thinned portion of the membrane situated behind the handle of the
malleus is curved inwards until it has come into contact with the articula-
tion of the stapes and incus and with the promontory (Fig. 116), immediately
after inflation, the portions of the inner wall of the tympanic cavity which
have been visible will disappear, and instead of the previous depression,
a grayish-yellow roundish or oval bulla (Fig. 117) will be observed in the
posterior portion arching over the handle of the malleus either partially or

* It is produced by the rapid change of the position of the membrane and of the
handle, by which the direction and relation of the vessels to those in the external
meatuN are suddenly changed, and a temporary stagnation in the veins of the handle
taket plaoew

Digitized by VjOOQIC

260 THB SBCBETING FOBM OF MIDDLE EAB CATARKH.

completely. The duration of such curvature outwards is, however, only very
short, as, in consequence of the speedy rarefaction of ftir in the tympanum, the
yielding portions of the membrane are forced inwards. In certain cases with
sero-mucous exudate in the middle ear partial bulging of membrane like a
ball takes place in the posterior superior quadrant (Fig. 118). They occur
generally with slight reactive symptoms, and form the transition from a
catarrh to an acute middle-ear inflammation. The connection of the tumour
with the cavtim tympani will be shown after the air-douche by the contrast of
the gray and yellow colours which the air and secretion form in the projection.

Symptoms. — As a rule the middle-ear catarrh runs its course
without pain, but in a few rare cases slight twinges of pain are
felt at the beginning of the disease and in inflammatory oedema
(Zaufal). More frequently, however, especially in recent catarrhs,
there is produced a sensation of fulness, numbness, and pressure
in the ear, similar to that felt when a little water remains in the ear
after a bath. This sensation, which is frequently very unpleasant,
is, according to my observation, in inverse proportion to the degree of
swelling and impermeability of the Eustachian tube, as that the more
trifling the swelling and deafness, the greater is the sensation of ful-
ness, which is generally completely wanting when the tube is quite
impermeable. The effort to relieve these sensations by means of
frequently shaking the finger placed in the external meatus is very
detrimental.

An important, though not a constant symptom, to which I was
the first to draw attention, and which is most frequently observed
in recent catarrhs, is the sensation as if a body were moving to
and fro in the ear when the position of the head is changed, a
feeling which frequently corresponds with the motion of the^exuda-
tion, visible through the membrana tjnnpani. If the membrane
is opaque, the presence of free exudation in the middle ear may
with probability be inferred from this symptom.

Subjective sensations of hearing in the secretive forms of catarrh
are not constant, but usually intermittent. They frequently occur
suddenly in cases where the disease becomes aggravated, accom-
panied by a sudden decrease in the hearing, and disappear just as
rapidly, when an improvement in the hearing takes place either
spontaneously or in consequence of treatment That in this form
x>i catarrh the noises are caused by the temporary increase of
pressure in the labyrinth will be seen from the fact that generally
immediately after inflation of the tympanic cavity, the tinnitus
either ceases altogether or is considerably diminished. In cases
where the tinnitus uninterruptedly continues for some time, and
in spite of treatment for an impermeable tube, the prognosis will

Digitized by VjOOQIC

SYMPTOMS. — FUNCTIONAL DI8TUBBAN0B8. 261

be un£ayoarable, because the noises must be considered as in-
dicating the development of permanent changes at the fenestrse
of the labyrinth or some lab3rrinthine complication. In cases of
exudation in the middle ear consecutive to pharyngeal syphilis, I
have frequently observed constant subjective noises. A frequent
symptom also in the secretive forms of catarrh is a crackling and
snapping in the ear, which is especially noticeable upon swallowing
and masticating.

The resonance of the patient's own voice is often one of the most
troublesome symptoms (Autophonia). It is more noticeable in one-
sided affections and in slight catarrhs than when both ears are
diseased. The echo of the patient's own voice often induces him
to avoid protracted conversations, and the attempts to remove
this troublesome sensation by clearing the throat and blowing the
nose, are successful only for a short time. Frequently this symptom
disappears during treatment ; it rarely remains after a cure of the
catarrh has been effected.

The sensations of heaviness and numbness of the head are sub-
jective phenomena of chronic catarrhs, to which special attention
must be given. Adults often complain of a feeling of pressure and
confusion in the head, through which they are rendered unfit for
mental work. In children these symptoms become apparent by
ill-humour and waywardness. All these phenomena generally dis-
appear with surprising rapidity after repeated Politzerization or
inflation by the catheter. Epileptiform attacks following simple
middle-ear catarrh have been frequently observed (Noquet) and the
relation of the two conditions proved by the cessation of the
epilepsy upon treating the catarrh.

Functional Disturbances. — The functional disturbances in the
catarrhs of the middle ear, accompanied by swelling and secretion,
are in most cases disproportionate to the known amount of effusion ;
the degree of the functional disturbance depending rather on the
abnormal tension of the membrana tympani and of the ossicula,
caused by the impermeability of the Eustachian tube.

Considerable fluctuations in the hearing-distance, not only on
difikrent days, but also at very short intervals^ have an important
diagnostic significance in this form of catarrh. This depends
partly on the variable tension of the sound-conducting apparatus,
partly also on the change in position of the secretion.

Fluctuations in the hearing-distance are produced by various
external and internal influences. In autumn and in winter, on
ramy and foggy days, the hardness of hearing vnth catarrhs of
the middle ear is, as a rule, more marked than in summer and in

Digitized by VjOOQIC

262 THE SECRETING FORM OF MIDDLE-EAR CATARRH.

dry weather. Abrupt change of temperature not unfrequently
causes a sudden aggravation, as does also the excessive use of
alcoholic beverages. The power of hearing is, however, subjected
to the most frequent fluctuations by becoming complicated with an
acute naso-pharyngeal catarrh or by exacerbation of a catarrh
already existing in the naso-pharynx.

Fluctuations in the hearing-distance frequently arise quite sud-
denly, and generally with the sensation of a report in the ear.
This symptom is specially observed in patients who, in consequence
of a continuous impermeability of the Eustachian tube, were very
hard of hearing for a considerable time, often for several months,
and in whom the air suddenly enters the tympanic cavity, either
in consequence of a spontaneous opening of the tube during an act
of swallowing — ^the swelling of the mucous membrane having sub-
sided to a certain degree — or on accoimt of the removal of a mucous
plug. Just as rapidly as the improvement in the hearing, theie
frequently takes place an aggravation with the sensation of a sudden
closure of the ear, or as if a wall were placed before it.

Perception through the cranial bones for the watch and the acoiuneter is
almost always preserved and not unfrequently is even heard more intensely.
It is only in cases of middle-ear catarrh complicated with labyrinth syphilis
that perception through the cranial bones is lacking* I wish to attach special
importance to this symptom, as on account of it I have repeatedly suspected
syphilis, a suspicion which was confirmed by minute examination of the case.
In Weber's test the tone of the tuning-fork will generally be localized in the
affected ear, and only exceptionaUy in the better one. When complicated by
labyrinth syphilis the tone will be localized generally in the normal or better
ear. In slight unilateral catarrhs with otherwise negative results, the lateral-
ization in the affected ear is an important symptom for the diagnosis of
middle-ear affection. Bimie's test in slight affections of hearing is positive ;
with more pronounced deafness it is often negative withjiengthened perception
through the cranial bones.

The results of auscultation in catarrhs of the middle ear accompanied by
swelling and secretion, and their diagnostic importance in the catarrhal
affections here under discussion, have already been referred to in detail in the
general division (p. 104).

Course and Issues^ — ^The catarrhs of the middle ear generally run
a protracted course. The course and issue are most favourable in
recent simple catarrhs, or in those which have originated in the
course of an acute cold in the head, as they subside spontaneously
or after treatment within a few days or may extend over several
weeks. Becent catarrhs after acute exanthemata, in influenza,
typhus, and in scrofulous ansBmic individuals, and with chronic
naso-pharyngeal affections, have a protracted course.

Digitized by VjOOQIC

COURSE AND ISSUES. 263

The result of recent catarrhs is either healing or transition into
the chronic state, more rarely in acute middle-ear inflammation
and perforation of the membrana tympani with a serous or sero-
mucous discharge for a short time. A fatal result after sero-
mucous catarrh from meningitis has only been observed in single
cases by Zaufal and Schwartze.

Chronic catarrhs, however, take a quite uncertain course. The
great tendency to relapses of catarrhs of the middle ear, favours
the transition of acute catarrh into the chronic state. After a
catarrhal affection has ceased, the mucous membrane of the middle
ear remains for a long time so sensitive to hurtful influences, that
a slight cold, a cold bath, or a somewhat severe cold in the head
suffices to produce a return of the exudation in the middle ear. It is
a peculiarity of such relapses, that the renewed process exceeds the
preceding affection in duration, imtil at last, after frequent relapses,
the catarrh becomes permanent, and changes are developed which
exclude the possibility of a complete restitution of function. Ee-
lapses are specially frequent in children, who are subject to either
temporarily recurring or permanent catarrhs of the naso-pharynx
with adenoid vegetations and hypertrophy of the tonsils. In such
cases the catarrh of the middle ear recurs simultaneously with the
naso-pharyngeal catarrh, mostly during the autumn and spring, and
generally subside partially or altogether when the warm season
comes on, to return again next autumn. In this manner catarrhs in
children may regularly recur for a number of years, frequently until
they are fourteen to sixteen years old, when the relapses will either
completely cease or occur more rarely.

Also in adults, chronic naso-pharyngeal catarrhs, and the changes
in the naso-pharynx produced by them, have a no less important
bearing on the course and issue of the affections of the ear under
discussion. Not only are they frequently the chief cause of the
disease of the middle ear, but its catarrhal condition is maintained
by the continuance of the naso-pharyngeal affection.

It has already been pointed out that the condition of the
Eustachian tube has a great influence on the course of catarrh
of the middle ear. It has to be added here, that even after the
exudation has been completely removed from the middle ear and
the hearing-function has returned to the normal state, a lasting
cure cannot be expected, as long as the permeability of the
Eustachian tube has not been established. Therefore, when treat-
ing catarrhs of the middle ear it must be our flrst endeavour to
make the tube permeable, this being one of the most important
conditions for normal hearing.

Digitized by VjOOQIC

2G4 THE SECRETING FOBM OF MIDDLE-EAIi CATABBH.

It is of importance, as regards both prognosis and treatment, to learn the
amount and the site of the sweUing in the tube. While an impermeability of
the canal produced by a swelling on the ostium tubse, which frequently occurs
in cases of adenoid vegetations in the naso-phar^Tix, offers Uttle resistance to
treatment after the removal of the naso-pharyngeal affection, extensive swell-
ngs in the tube produced by tumefaction and induration of the mucous
membrane of the naso-pharynz require a protracted course of treatment, or
are incilrable. According to Hartmann it may be inferred that a swelling is
confined to the ostium tubs, if the air, propelled after my method, enters
into the middle ear under great pressure only, while when the catheter is
applied the air flows in freely and with the slightest pressure. If, however,
great pressure is also required during catheterization, a diffuse swelUng,
extending over the whole tube, may be inferred.

The influence of the exudation upon the course of the pathological process
depends less upon its quantity than its quahty. The quantity of the exuda-
tion is by no means always a gauge of the intensity of the process, as generall.^
in cases of trifling swelling a very copious secretion is discharged, while when
a great softening of the mucous membrane is demonstrable, only a small
quantity of free secretion is effused into the tympanic cavity. According to
experience, affections of the latter kind resist treatment more obstinately than
catarrhs accompanied by a copious discharge.

Begarding the effect of the quahty of the exudation upon the course of the
disease, it may be remarked, that the Uquid secretions can be reabsorbed
with much greater rapidity, and can be removed much more easily from the
tympanic cavity, than the tough, syrupy, adhesive mucous masses.

It is beyond doubt that injurious consequences may be developed througli
the production of permanent pathological changes, caused by the protracted
stagnation of the secretion in the middle ear. The purulent processes, such
as are observed sometimes in the comrse of chronic catarrhs, especially in
children, are probably often produced by bacterial infection of the secretion in
the middle ear. An^ exudation which has not been reabsorbed may also
produce a permanent h^-perffimio condition by protracted contact with the
mucous membrane, which may lead to cell-gro^'th and to adhesive connective-
tissue growth in the middle ear.

Besides the above enumerated conditions we must point out those general
diseases which affect the course and issue of catarrhs in an imfavourable
manner. Catarrhs also run an unfavourable course in cases of tuberculosis,
Bright's disease, anaemia, marasmus, exhausting diseases and all cachexife, by
which the nutrition of the general system has become deteriorated. In
s^'philitic patients sero-mucous exudation of the middle ear takes a relatively
favourable course, even if combined with disease of the labyrinth.

But even in quite healthy people, in simple catarrhs as well as in those
originated by extension from the naso-pharynx, and independently of
the duration of the affection, adhesive processes in the middle ear are
frequently developed. While, according to experience, many catarrhs even
such as have existed for many years, completely subside, and therefore (if I
may make use of the expression) presen-e a benignant character for a long
time, wd may find, on the other hand, even shortly after the commencement

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DIAGNOSIS. — PB0ON08IS. — TBEATMBNT. 265

of a slight catarrh, that changes arise in the middle ear which permanently
impair the hearing.

Dia^gnosia, — ^The diagnosis of secretive middle-ear catarrh is
proved by seeing the secretion in the middle ear shining through
the membrana tympani. When there are opacities in the mem-
brana tympani which preclude the view of the secretion, the
diagnosis can only be made by considering the results of ausculta-
tion, the great variation of the hearing-distance, and the marked
increase in the hearing-distance after the air-douche. In such cases
a collection of secretion can only be proved by paracentesis of the
membrana tympani.

Prognosis. — The prognosis will be most favourable in recent simple
catarrh, when the patient is otherwise hi^fiiy, when a hereditary
tendency can be excluded, and when the paflint is living in favourable
circumstances which permit him to avoid external sources of injury.
A considerable increase of the acuteness of hearing after the
Eustachian tube has been rendered permeable, or after removal of
the secretion from the middle ear, leads us to expect a favourable
issue. In existing naso-pharyngeal affections the prognosis will be
more favourable if simple swelling of the mucous membrane has to
be dealt with, and no advanced, deep-seated changes in the mucous
membrane have taken place. In the simple catarrhs of the tube the
prognosis is relatively good if they are not combined with obstinate
affections of the naso-pharynx.

The conditions which make the prognosis unfavourable are hereditary dis-
position, old age, continuous subjective noises, frequent relapses, long duration
of the catarrh ; and if after the Eustachian tube has been made permeable
and the secretion has been removed, only slight increase in the hearing-
distance follows; if perception through the cranial bones is decreased and
shortened ; if the catarrh is combined with obstinate forms of ozsena or of naso-
pharyngeal blennorrhoea ; restrained action of the muscles of the tube
(paral^'sis of the palate, cleft palate) ; the existence of a general disease
accompanied by anaemia or cachexia ; or if the patient, on accotmt of his
mifavourable condition in life or on account of his calling, remains exposed
to unfavourable external influences, and if he is a drunkard, or smokes
excessively.

Treatment. — ^The most important indications to be taken into
consideration in treatment of catarrhs of the middle ear, accom-
panied by swelling and exudation, are the establishment of the
permeability of the Eustachian tube, the removal of the exudation
from the tympanic cavity, and of the swelling and secretion in the,
mucous membrane of the middle ear. If, however, a naso-pharyngeal
affection exists, it must be treated at the same time as the local

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266 THE SECKETING FOBM OF MIDDLE-EAB CATARRH.

affection, and the general health, as well as the circumstances in
which the individual lives, must be taken into a^ccount. As thera-
peutic expedient we will first consider :

1. The Air-douche in the Middle Ear.— In middle-ear catarrh
with secretion, the air-douche, according to the author's method,
attains the best result, in adults as well as in children. In the
catarrhs of the cavum tyrapani and Eustachian tube so common in
children, it has proved indispensable. The most marked and
permanent improvement in hearing is produced by the method
combined with swallowing. In children who will not perform the
act of swallowing, the air may be forced in without it or while they
speak a word (Konig, Barique ; vide p. 119), Th^ air-douche should
be repeated 2 to 3 times at each treatment.

If the resistance in tht^middle ear is so considerable that propell-
ing air by my method does not succeed at all, or only imperfectly,
inflation by the catheter must be resorted to, with the aid of the
ordinary air-bag, or, if the resistance is too great, by means of
the force-pump. Experience skows that in case of great resisteiioe
it is frequently sufficient merely to apply the air-douche once, by
means of the catheter, to lessen the obstruction, and that afterwards
the treatment may be successfully continued by propelling air after
my method.

Where, however, the air penetrates powerfully into the middle ear
during the application of my method, the air-douche by means of
the catheter is contra-indicated, because, as already mentioned, the
frequent immediate contact of the hard instrument with the diseased
mucous membrane of the tube may only increase the swelling and
secretion in the middle ear.

The air-douche in the middle ear in secretive catarrhs is generally
followed by a marked improvement in hearing. With slight swell-
ing of the tube and a small amount of accumulated secretion the
impirovement in hearing lasts some time. In excessive swelling of
the tube with copious tenacious exudates the improvement in hear-
ing generally disappears very rapidly. The great variations which,
are marked at the beginning usually become less as treatment is
continued. It is of importance, as the constant increase of the
hearing -distance signifies a decrease of the catarrh, while the
disappearance of this improvement in hearing is a symptom of
undiminished continuance of it.

By means of the air-douche the accompanying head symptoms
(pressure, heaviness and confusion) will be often quickly allayed.
The effect is most marked in children in whom not only the un-
easiness, ill-humour and aprosexia (Guye) disappear, but also the

Digitized by VjOOQIC

TREATMENT. 267

unhealthy appearance and sickly colour disappear after a short
time.

The duration of the treatment of catarrh of the middle ear by
means of inflation after my method, depends on the results it pro-
duces. At first it is advisable to inflate daily, as long as the im-
provement in the hearing passes away for the most part again from
day to day. If, however, after treatment for several days no con-
siderable decrease in the hearing-distance is observable, the method
is repeated every second, and then every third day, and if the
improvement continues, at still greater intervals, once or twice a
week, and &uklly only once a week, until no fluctuations in the
hearing-distance can be noticed.

By methodical inflation in this imy, a complete cure is effected
in the secretive forms of catarrh of the midAs Bar, not only in
recent, but also frequently in chronic cases, without any loitiba:
local treatment. The advantages of this method of treatment,
compared with that by the catheter, are sufficiently apparent
from the number of cures since my method has become generally
known; for no one can deny that the percentage of cured and
improved patients is now considerably greater than it was when
nothing but the catheter was used*

Besides the air-douche in the middle ear, in the majority of cases
in which the middle-ear catarrh is combined with retraction of the
membrane, rarefaction of air in the external meatus by means of
Delstanche's masseur should be done after each application
of the air-douche. Through the combination of both methods the
effect of the treatment will be appreciably increased as well in
regard to improvement of hearing as also in diminishing the sub-
jective noises and annoying head symptoms.

2. Mechanical removal of Secretion from tlie Middle Ea/r. — The
mechanical removal of the secretion from the middle ear is indicated
when, owing to the large amount secreted and to its tenacious
character, absorption is not brought about by means of the air-
douche. This is effected either after a method invented by me, or
by means of paracentesis of the membrana tympani.

For cases in which the exudation in the tympanic cavity is almost
entirely serous, I several years ago devised a method of removing
the secretion from the cavity without paracentesis of the membrane.
The head of the patient, after he has taken a little water into his
mouth, is placed in a position inclined well forwards and somewhat
towards the opposite side, which causes the pharyngeal orifice of the
Eustachian tube to point directly downwards, while the ostium
tympanicum tubsB is directed exactly upwards. This position of

Digitized by VjOOQIC

268 THE SECRETING FORM OF MIDDLE-EAR CATAJIRH.

the bead is retained by the patient for one or two minutes, so that
the secretion contained in the depressions of the tympanic cavity
may flow towards the orifice of the tube. Then air is propelled after
my method during an act of swallowing, to allow the secretion, now
deposited above the ostium tubsB, to flow into the naso-pharynx
by opening the Eustachian tube. If shortly after this manipulation
the membrana tympani is examined in its normal position, instead
of the yellowish lustre produced by the exudation, the membrane
will be found to be light gray, and in those cases in which the line
of the level of the exudation was visible belore inflation, it has either
completely disappeared, or is considerably lower than before.

In this manner it is possible to remove the accumulated exudation
from the middle ear if serous, but in those cases, however, in
which the exudation forms a tough, gelatinous, consistent mass
of mucus, its escape through the tube cannot be effected in the
above manner.*

Paracentesis of the membrana tympani, to effect the removal of
mucous masses from the tympanic cavity, was performed by Itard,
Busson, Frank, Bonnafont, and Philippeaux, but without precise
indications. To Schwartze belongs the merit of having introduced
it into practice, so that it is now in general use, and I consider
this operation, after an abundant experience, to be one of the most
practically important and successful therapeutic expedients in
diseases of the ear.

Paracentesis of the membrana tympani is indicated in those cases
in which, after the application for several days of the methods of
treatment already described, no decrease of the exudation is observed,
and in which, even when no exudation is demonstrable, the im-
provement in hearing, the immediate result of inflation, disappears
again almost entirely in one or two days. I also frequently perform
the operation in those oases in which at the first examination the
accumulated exudation is seen to be copious, while by this means a
complete cure may be accomplished in a few days. The great
advantage of this operation lies therefore in shortening the duration
of treatment.!

Paracentesis of the membrana tympani is an operation so simple and easy
of execution, that it can be performed by every practising physician.
The instnunent used for the operation is a double-edged lancet, 6 ctm.

* The aipirAtioD of the secretioa from the cavum tympani through the tabe by
means of the Weber-Liel tympanic catheter has proved insufficient for its removal.

t DiagnoBt, und Therapie der Ansammlung serdser FlUssigkeit in der Trommd-
hChlt^ Wien. med, Wochenschri/t, 1867, and Weber bewegliehe Kxgudate in der
TranmelhdfUe, Med, Presse, 1869.

Digitized by VjOOQIC

TREATMENT.

369

long, and with a knee-like bend near its handle, to whieh it is either firmly
united or can be fastened by means of a small screw (Fig. 110). The latter
instrument has the advantage that the lancet can be adjusted in different
directions, and therefore the incision into the membrana tympani can be
made with it as easUy in a vertical as in a horizontal direction. Previous to
the operation, the point of the lancet must be examined to ascertain that it is
intact, because the pain during the operation is increased by the slightest
bluntness of the instrument. Immediately before
the operation the lancet should be disinfected by
dipping in a 8 per cent, carbohc solution. Rohrer
recommends the application of a 20 per cent,
solution of cocaine to the part of the membrane
where paracentesis is to be performed.

The most suitable site for the incision into the
membrana tympani is its posterior inferior quadrant,
because this place is easily accessible, and is re-
moved further from the inner wall of the tympanic
cavity than the portion of the membrane situated
inmiediately behind the umbo, where during in-
cision the promoniory might easily be injured. If
the posterior wall of the external meatus is only
slightly curved, the anterior inferior quadrant (Figs.
120 and 121), which is also some distance from the
inner wall of the tympanic cavity, may be chosen.
If the membrane is strongly curved forward, the
most prominent point of the bulging is incised.

The direction of the incision has no influence on
the duration of cicatrization. For less experienced
operators, Bing proposes the use of a horizontal
incision, because the walls of the external meatus
are not so easily injured in making such an incision
as in making a vertical one.

The operation itself is performed in the following
manner : The head of the patient, who is seated, is
fixed either by an assistant, or by placing it against
a head-rest. A speculum as wide and short as
possible is inserted into the meatus, and the mem-
brana tympani is iUuminated by a light thrown into
the meatus by means of a forehead mirror.

While the speculum is fixed in the meatus with the fingers of the left
band, and the place on the membrana tympani where the incision is in-
tended to be made is closely kept in view, the instrument, held by the
thumb, forefinger and middle finger of the right hand, is introduced into
the meatus as far as the membrana tympani, the layers of which are
rapidly cut by lowering the point of the lancet, and while removing the in-
strument the incision is widened to 2-8 nmi. It is better to make the open-
ing too large than too small, as tenacious masses of mucus will either
not pass through a small opening or only with difficulty. The operation,

Fio. 119.— liANcrr with

ADAPTABLS HaNDLK.

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270

THE SECBETING FOBM OF MIDDLE-EAB CATABBH.

which is seldom painful, must be executed rather quickly with children and
nervous patients, but always without precipitation, because from a hasty
introduction of the instrument, when the eye cannot follow its point, the
external meatus is frequently incised instead of the membrana tympani.
Injury to the bulbus yenie-jugular, which has been obser\'ed twice (Ludewig,
HOdebrandt), occurred through the abnormal dehiscence of the floor of the
cavum tympani. They progressed favourably upon quickly tamponing.

Immediately after paracentesis in the somewhat gaping incision, a weak
pulsation of the fluid or a distinct motion of it will be observed during speech
or the act of swallowing. It is only rarely that a small drop of fluid exudes
through the orifice to the external surface of the membrane ; frequently,
however, immediately after the operation, especially if the secretion is serous,
several bubbles will be seen rising up behind the membrane during an act of
swallowing, due to the entrance of air through the orifice. Sometimes a
loud cracking noise will be heard in the ear during deglutition, when the
margins of the perforation gape.

Fig. 120.— Vebtical Incision in kbont

OF AND BBLOW THB HANDLE OF THE

Malleus.

Fio. 121.— Horizontal Incision in the
Anterior Inferior Quadrant.

To remove exudation from the tympanic cavity after paracentesis
it is necessary to inject air forcibly, and then the full effect of the
operation is obtained. In almost all cases it will be possible to
drive out the masses of secretion through the incision into the
external meatus by means of my method, and that more com-
pletely than can be done by Valsalva's method or the catheter.
Only in isolated cases, in which the resistance in the middle ear is
very great, or in which, in consequence of paresis of the muscles of the
palate and of the Eustachian tube, their action becomes insufficient
during the act of swallowing, will it be necessary to inject air through
the catheter into the tympanic cavity. But it may happen that the
secretion can be more easily removed by blowing the nose violently
than by the catheter or my method. Eohrer recommends disinfec-
tion of the naso-pharynx with a 6 per cent, solution of hydrogen
peroxide before using the air-douche.

The success of the operation depends chiefly on the complete removal of
the secretion from the tympanic ca\ity. It is, therefore, advisable to apply

Digitized by VjOOQIC

TREATMENT. 271

my method three or four tunes in sncoeBsion. Air and secretion pass into
the external meatus, if the secretion is liquid, with a hissing and rattling
noise; if the mucous masses are tenacious, however, either without any
noise or with a grating sound. If the membrana tympani be then inspected,
it will be found covered either with a frothy fluid, or with a yellow or brownish
mucous mass. If there is only a slight quantity of tenacious exudation, the
air frequently passes through the perforation without ejecting it. On the other
hand, if there are great masses of exudation, and if the incision in the
membrana tympani has been made too small, the mucus is jammed into the
orifice of the perforation, while a portion of it hangs out like a yellowish -
j^reen mass with a pearly lustre.

If in such cases it is impossible to force the secretion from the tympanic
cavity into the external meatus by repeated inflations, I employ rarefaction of
air in the external meatus, for which Delstanche's masseur is especially
suited ; and I also make use of this method for the removal of exudation
from the tympanic cavity in those cases in which the catheter cannot be
introduced into the Eustachian tube in consequence of malformations in the
naso-pharynx or other causes, or where the tube is closed by stricture or
adhesion. I have often succeeded in removing all the secretion from the
middle ear by rarefying the air in the meatus when the means by condensing
the air failed. If this means is also not successful in removing tenacious
secretion from the cavum tympani into the meatus, it is adiisable to force
it through the tube into the pharynx by forcibly compressing the air in the
external meatus. If this method also fails, on account of the small opening
in the membrane, it will be necessary to enlarge the incision.

The secretion that escapes into the external meatus flows ofl* partially when
the head is inclined towards the same side. Since serous secretion, as I have
several times observed, flows partially back into the tympanic cavity after it
has been propelled into the external meatus, I push a small pellet of wadding
in front of the perforation, before propelling air for the second or third time,
by which means the ejected secretion is absorbed, and cannot return into the
t;s'mpanum. Tenacious mucus may be taken hold of with the bent forceps
and pulled out, or removed by strongly forcing the air into the external
meatus several times by means of a balloon. Injections of tepid water into
the external meatus, which are recommended for the removal of mucus,
should be avoided, as they may readily produce inflammatory irritation.
The aspiration of the secretion through the paracentesis opening by means of
a small canula inserted through it has proved worthless.

I am still more opposed to copious injections of solutions of common salt
and soda through the catheter (v. Troltsch), recommended for the hquef action
of tough mucous masses, because they frequently produce violent reactive
inflammation by irritation of the mucous membrane of the middle ear and
of the margins of the wound, from which protracted suppm^tion may follow.
The same applies to forcible syringing of the tympanic cavity from the ex-
ternal meatus by means of a syringe, the olive-shaped nozzle of which is
inserted hermetically into the external orifice of the ear.

Immediately after paracentesis, and frequently even before the removal of
the secretion, relief is felt in the ear in consequence of the slackening of the

Digitized by VjOOQIC

272 THE SECBETING FOBM OF MIPDLE-EAR CATARRH.

membrana tympani, and a remarkable improvement in the hearing may at
onoe be discovered, which increases after the removal of the secretion from
the tympanic cavity.

The nnion and closure of the margins of the incision take place generally
within twenty-four hours (Schwartze), rarely only after 2-8 days. Occasion-
ally a serous or syrupy secretion accompanies the operation, lasting several
days. Consecutive inflammation of the membrana tympani and of the
mucous membrane of the middle ear, which was observed by Schwartze in
25 per cent, and by Christineck in 41 per cent, of the cases, I have seen ver^'
rarely in the great number of cases operated on by me (1 : 800), although the
operation was frequently performed in winter in patients going about as usual.
I attribute this good result partly to the careful antiseptic precautions carried
out, and partly to avoiding all irritation to the membrane and cavmn tympani
after the operation.

To avoid aU sources of danger, which might produce inflammation of the
membrana tympani, the meatus must be kept closed with carbolized cotton-
wool on the day of the operation, the patient must abstain from all heavy,
heating work, and from exciting spirituous liquors ; he must also avoid rapid
changes of temperature and close and smoky rooms.

HyperiBmia, ecchymoses, and opacity of the membrane disappear in a
short time ; only rarely there remains a cicatricial depression on the spot
where paracentesis was performed or partial atrophy of the membrane.

As regards the curative eflect of paracentesis, I have observed in more than
one-third of the cases operated on, especially in those of recent origin, a
complete cure after once performing the operation. These are oases in which
the exudative process had already ceased, the hardness of hearing being
caused by the mechanical action of the exudation alone.

In cases in which the eflusion from the mucous membrane of the tympanic
cavity still continues, especially when there is great permanent swelling
of the tube, another accmnulation or exudation in the tympanic cavity will
take place in a short time, so that paracentesis has to be repeated several
times. In collections of fluid with atresia of the tube and facial paralysis the
paracentesis, on account of its temporary eflect, must be repeated at intervals
for years.

The preservation of the permeability of the Eustachian tube by means of
Politzerization, and the local treatment of naso-pharyngeal catarrhs, if such
exist, are of importance in preventing relapses. What influence repeated
inflation of air after the operation has upon the course of the disease, may be
seen from the fact that in cases where two or three days after the operation
a slight quantity of exudation, distinguishable by the line of its level, had
again been formed, it was made to disappear after applying my method several
times.

It is therefore absolutely necessary, in order to maintain the improvement
that has been efiected, to continue the injection of air by my method after
the operation for several weeks or months, at first two or three times a week,
later once every eight or fourteen days until cured.

If no constant improvement in the hearing is efiected in spite of the
thorough removal of the secretion, this may be traced either to a continuance

Digitized by VjOOQIC

TBEATMENT. 273

of the tumefaction of the mucbos membrane of the Eustachian tube and of
the tympanic cavity, to an anomaly of tension of the membrana tympani,
or to adhesive processes which often occur, even during the discharge of
secretion, thickening of the mucous membrane, rigidity of the articulations of
the ossicula and adhesions. Swelling of the tube can be most surely proved by
auscultation during catheterization. That the deafness is owing to anomalies
of tension in the sound-conducting apparatus may be inferred if the tube is
permeable and no secretion in the middle ear, in spite of which marked
improvement in hearing occurs upon using the air-douche, which disappears
again upon the membrane retinming to its former position. The existence of
adhesive changes may with probability be inferred if after the removal of the
secretion, as well as after repeated inflations, no material improvement
in the hearing results after several days. If besides there are subjective
noises, which are not altered by paracentesis, it is hardly doubtful that in
such a case we have to deal with a process of condensation at the f enestrse of
the labyrinth.

The swelling of the mucous membrane of the tube remaining after the
secretion is removed will either subside spontaneously or after the use of the
air-douche. Only when the duration of the catarrh is protracted should
medicated appUcations be made to the swollen mucous membrane. The
injection of medicated solutions into the cavum tympani is not only of little
use in the secretive forms of catarrh, especially when there is secretion
present, but often produces very considerable harm. On the other hand, in
obstinate swelling of the tube, localized medicated applications to it are often
very effective. In order to introduce the medicine into the tube, without
having it penetrate into the cavum tympani, eight or ten drops of the solu-
tion should be injected into the catheter with a Pravaz syringe, while the
patient's head is bent to the side and a little backwards, by which means the
fluid flows from the catheter into the tube. In this way concentrated solu-
tions (Zinc, sulph. 2 in 10, Argill. acet. Burowii''^) may be applied to reduce
the swelling of the tube. In obstinate cases astringents are sometimes suc-
cessful only when preceded by injections of ammonium chloride solution
(1 in 20-80) or soda bicarbonate (8 in 10-20). Steam and anmionium chloride
vapour, as reconmiended by v. Troltsch and BQrkner, rarely reduce the
swelling of the mucous membrane of the tube. Turpentine vapour has
proved more useful, it being aspirated from the vial with the balloon and
forced through the catheter into the middle ear. Bronner (Arch, of Otology,
1891, voL zx.) reconmiends the vapour of Ol. eucalypti and menthol.

The application of medicated fluids to the mucous membrane of the tube
is most effective if alternated with the air-douche by means of my method or
the catheter (on one day the injection, the next the air-douche). The improve-
ment in hearing from this combined treatment is generally very noticeable.
Where fluid injections act unfavourably one must return to the use of the air-
douche alone.
Where the swelling of the tube is persistent, and the air can be forced into

* Alum, cmdi 70*0 ; Sol v. in aqua dest. 280*0 ; Plumb, aoet. cryst solve in
aqua dest. 280*0 ; Liqu. mixt. filtra et dilue pond. 800 '0. Serv. in vitr. bene
dauso.

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274 THE CATABBHAL ADHE8IVB PROCESSES IN THE MIDDLE EAB.

the ear only with difficulty, the introduction of medicated bougies into the
tube are reconunended (Albert H. Buck). I use most frequently catgut
bougies (thin violin strings), which are impregnated with a concentrated solu-
tion of nitrate of silver (1 in 10), then dried and pushed through the catheter
as far as the isthmus tubs and left there for three or five minutes. Often after
the third to fourth introduction of these bougies (every 2-8 days) the passage of
the tube is open, so that air may be forced through by my method. If these
bougies soaked in the silver solution be left in the tube too long they may
produce reactive middle-ear inflammation. In swelling of the tube which
has lasted a long time, I have used with advantage massage (2-8 minutes)
below the auricle on the side of the neck between the inferior maxilla and the
mastoid process.

In catarrhs of the tube and cavum tympani which had resisted all treat-
ment, I have often seen complete healing take place if the patient at the
beginning of warm weather went to reside in the Alps.

In secretive middle-ear catarrhs the treatment should not be continued
more than a certain time, as I have previously mentioned. As the same rules
apply here as in catarrhal adhesive processes (dry catarrh) of the middle ear,
I would refer to the treatment in the next section. Under the head of naso-
pharyngeal affections will be considered the after treatment, hygienic circum-
stances of the patient, the diet, etc.

(b) The Catarrhal Adhesive Processes in the Middle Ear.

Syn. : Otitis media catarrhalis chronica; Otitis media catarrhalis sicca;
Otitis media sclerotica ; Proliferous inflammation of the middle ear (Boosa) ;
Otitis media iperplastica (de Bossi).

Catarrh of the middle ear, accompanied by sero-mucous exuda-
tion, having been described in the previous division, we will in the
present one discuss those adhesive processes which arise in the
course of chronio catarrh, and form the basis of permanent defects
in hearing.

Attention has already been specially drawn to the fact that a
sharply defined separation of the exudative catarrhs of the middle
ear from the adhesive processes which are developed from them,
is not practicable. For whil§ those anatomical changes, yet to be
described as permanent obstacles to the conduction of sound, are
generally developed only after the catarrhal exudation has passed
away, it has been sufficiently proved by pathological observations
that the new-formation of adhesive connective tissue very often
takes place even during the exudative stage of the disease, and that
in the course of many adhesive processes the catarrhal secretion
does not cease, but is continuous throughout.

It has also been specially mentioned, that adhesive processes in
the middle ear do not always originate in exudative catcurrh, but

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THS CATABBHAL ADHESIVE FBOCESSES IN THE BilDDLE EAK. 275

often, without a preceding catarrh, an insidious interstitial inflam-
mation is established in the lining membrane of the cavity, during
the course of which rigidity of the ossicular chain, but most
conmionly anchylosis of the stapes, results, owing to condensation
and contraction of the lining membrane and of the ligamentous
apparatus in the tympanic cavity. These are the diseases of un-
favourable prognosis, commencing usually with trifling symptoms,
showing, as a rule, an insidious course, and ending in the highest
degree of defective hearing.

The adhesive processes here outlined are much more frequently
accompanied by symptoms which point to a simultaneous affec-
tion of the labyrinth, than other forms of inflammatioiL The
insidious forms especially, which often end in anchylosis of the
stapes, are more frequently combined with disease of the labyrinth
than the adhesive processes arising from true catarrh. However,
affections of the labyrinth (atrophy, fatty and colloid degeneration)
often occur in conjunction with the last-named forms, especially if
of long duration.

After a short duration of the disease, or even at its commence-
ment, a combination of symptoms is frequently present which
leaves no doubt as to the presence of disease of the labyrinth.
With such decided labyrinthine symptoms appearing even at the
outset of the affection, we are often driven to the assumption from
clinical observation, that both divisions of the ear, the tympanum
and the lab3rrinth, have been affected at the same time and by
the same disorders of nutrition ; in the beginning of the disease,
however, the labyrinthine disturbances sometimes prevail to
such an extent that we must doubt whether in such cases the
primary disease did not originate in the labyrinth, and the develop-
ment of the obstacles to the conduction of sound did not occur
later.

From the foregoing it can be seen, that many various forms of disease
of the middle ear have been comprehended in the group of adhesive
processes, showing many ajiatomical as well as clinical differences.
The association of those interstitial inflammations of the middle
ear, so singular in their course, and chiefly confined to the neigh-
bourhood of the labyrinthine fenestraB, with the adhesive processes
originating with catarrhs, according to the present state of our know-
ledge is based only on the fact that obstacles to the conduction of
sound exist in both forms. As v. Troltsch correctly remarks, there
is no doubt that, through extension of our anatomical knowledge,
this interstitial form of inflammation may attain to a separate
position in the series of diseases of the ear. For in those cases

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276 THE OATABBHAIi ADHESIVE PROCESSES IN THE MIDDLE EAB.

where from its commencement it progresses without catarrhal
symptoms, it appears as a distinct disease, showing in the majority
of cases quite a different character from that of the adhesive pro-
cesses originating in true catarrh.

Pathologico-anatomical Alterations. — ^The pathological alterations
in the adhesive processes either extend over the whole mucous
membrane of the middle ear, or occur in circumscribed areas. The
former may be called diffused, the latter circumscribed inflammatory
processes. The diffused changes most frequently arise &om the
secretive forms of catarrh of the middle ear, while the circum-
scribed obstacles to the conduction of sound, especially those which
are developed in the neighbourhood of the fenestrae of the labyrinth,
are mostly products of the interstitial form of inflammation of the
mucous membrane (sclerosis).

The structural changes in the mucous membrane consist generally in partial
or total transformation of the new-formed round cells into fibrous connective
tissue, interstitial hypertrophy of the mucous membrane with retrograde meta-
morphosis of the new-formed tissue, shrinking, sclerosis, atrophy, and cal-
cification.

In cases where the exudative stage has not yet passed away, the hypersemic
mucous membrane, usually unevenly tumefied, appears yellowish or bluish-red,
infiltrated with senun, gelatinous, spongy, easily movable, uneven in surface,
glandular, and shaggy. In consequence of this excessive proliferation of the
mucous membrane, the depressions in the tympanic cavity, especially the
niches of the fenestrse ovalis and rotunda, as well as the attic of the caMun
tympani, are filled with succulent connective tissue, partially of new formation,
which covers the head of the malleus and body of the incus. Occasionally
the mastoid antrum and mastoid cells are filled with masses of oedematous
connective tissue, or that inconstant fibrous network which extends from the
malleus and incus into the mastoid antrum (p. 86) is thickened and hyper-
trophied. The mobility of the ossicula is impaired, but seldom quite lost by
anchylosis at this stage (Zaufal). The increase in thickness of the lining
membrane is caused partly by proliferation of the round cells, partly by new-
formed connective tissue. Therefore, by the round cells undergoing fatty
degeneration, a partial repair of the mucous membrane may take place.

In other cases where the secretion has totally ceased, and where a complete
transformation of the new-formed tissue into connective tissue has already
taken place, we find the mucous membrane generally smooth, several times
as thick as usual, pale, of a dull, tendinous-gray colour, rigid, firmly united
with its base, and only slightly movable. The condensation and rigidity
affect not only the lining membrane of the tympanic cavity, but often also the
folds of the mucous membrane and the ligaments which extend to the ossicula,
as well as the covering of the articular capsules. This thickening is generally
most strongly marked where the ossicula touch the walls of the tympanic
cavity. Oxily rarely partial calcification of the mucous membrane occurs
and mostly on the promontory, as well as hyperostotic narrowing of the

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PATHOLOaiCO- ANATOMICAL ALTERATIONS.

277

cavum tympani (Moos and Steinbrtigge).''^ In those insidious caseSi which
occur quite often, limited to the niche of the fenestra ovalis and producing
anchylosis of the stapes, the mucous membrane in the pelvis ovalis seldom
exhibits any macroscopical changes, as the process of shrinking and calci-
fication takes place more deeply in the layers of the periosteum.
In yet another series of cases we find the tympanic cavity traversed by

,^^-«^

'^^..yv

Fig. 122.— Niche of thk Fknestba Ovaus, with the CauBiB of the Stapes in

THE NOBMAL BaR OF AN AOULT. NeTWOBK OF BaNDS EXTENDING FBOM THE NbCK

of THE Stapes to the Walls of the Niche.

Cf Head of the stapes ; as, Crars of the stapes.

nimierous membranous strisB and bands, which often cross each other, and
by which the membrana tympani, the ossicula, and the tensor tendon, are
abnormally connected with each other and with the walls of the tympanum,
producing abnormally increased tension of the sound-conducting apparatus

Fig. 123. — Cboss Section thbouoh the Niche of the Fenestra Ovaus and

THROUGH both CRURiB OF THE StAPES IN A NORMAL EaB.

«, Section of the posterior free crura of the stapes ; a', Section of a bridge of muconF
membrane, with the anterior crura adherent to the wall of the i2che.

with deafness of different degrees. These bands cannot be considered as
primary pathological formations, but as thickened bands and folds which are
so often met with in the normal ear as residue of the fcetal mucous membrane
cushion (Fig. 122). In some rare cases such stris are transformed by a

* Steinbriigge, Pathologiache Anatomie dea Ohrts, in Ziegler's PcUholog, Anatomit^
1890.

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278 THE CATABBHAL ADHESIVE PBOCESSES IN THE MIDDLE EAB,

deposit of calcareous salts into bone-like processes (Toynbee, v. Troltsch).
We further find circumscribed or extensive adhesions between the membrana
tympani and the inner wall of the tympanic cavity, and sometimes a partial
or complete obliteration of the attic of the whole cavum tympani, by trans-
formation of its excessively proliferated mucous membrane into connective
tissue, and its complete and general union with the inner surface of the
membrana tympani and the covering of the ossicula.

Through these alterations in the tympanic cavity, the power of vibration of
the conducting apparatus is more or less impaired. The greatest obstacles to
conduction arise from the intimate attachment of the ossicula to the walls of the

Fig. 124.— Adhesion of the Crura of the Stapes with the Lower Wall of
THE Pelvis Ovaus, from the Left Ear of a Woman aged 48 Years, who

GRADUALLY GREW DeAF, THE LeFT £aR DATING SINCE 20 YeARS, THE RiOHT

10 Y'ears. Microscopical Section through the Pelvis Ovalis and the
Crura of the Stapes.

p, Pelvis ovalis ; o, Upper wall of the niche ; n, Mucous membrane of the lower
wall of the niche, which is infiltrated with fibrous sclerosed oonnective tissue ;
8tf 8tf Sections of cnirs of the stapes covered with tough fibrous oonnective tissue.
(After a preparation in my ooUection.)

t\anpanic cavity and from anchylosis of the ossicular joints. This anchylosis
is due to the formation either of a tense fibrous tissue (anchylosis membranacea
s. spuria), or of osseous substance (anchylosis ossea s. vera). The anchylosis
affects either all the ossicula, or each of them may be separately imited with the
adjoining walls of the tympanic cavity. We find, therefore, sometimes an
anchylosis between the head of the malleus, alone eft together with the body
of the incus to the tegmen tympani or the external wall of the tympanic
cavity. Several times in congenital deafness I have found the long process of
the incus adherent to the posterior wall of the cavum tympani.

Among the most important results of chronic inflammation of the mucous
membrane of the middle ear, is anchylosis of the stapes with the fenestra
ovalis. This lesion has been known since the time of Morgagni, who was the

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ANCHYLOSIS OF THE STAPES. 279^

first to describe and show preparations of it. To Joseph Toynbee, however,
belongs the great merit of having shown, by numerous post-mortem examina-
tions, that those disturbances of hearing, which formerly were classed under
the name of ' nervous deafness,* are caused by it in the majority of cases.

The anchylosis of the stapes is generally the result of a diffused inflamma-
tion of the mucous membrane of the tympanic cavity, and is often compli-
cated with anchylosis of the malleus and the incus, with adhesions between
the membrana tympani, the ossicula, and the inner wall of the tympanic
cavity, and with the formation of striae and bridges in that cavity, sometimes
also with thickening and calcification of the membrane of the fenestra
rotunda.*^ Often, however, it follows from circumscribed interstitial inflam-
mation of the mucous membrane, when the pathological changes are prin-

FiG. 126.— -Horizontal Section thbouoh the Kiche of the Fsnbstba Ovalis
AND Stapes of a Man aged 77, who was nearly Deaf. Adhesion of the
Posterior Crura of the Stapes wifh the Corresponding Wall of the
Kiche.

p, Base of the stapes ; at, Head of stapes ; a, a', Stapedio-vestibular articulation ;
V, Adherence of the cnis poet, stapedius with the wall of the niche. (After a
preparation in my collection.)

cipally confined to the neighbourhood of the fenestra ovalis, no signs of
disease being visible in the other portions of the middle ear.

Anchylosis of the stapes arises either through a imion of the margin of its
footplate with the circumference of the fenestra ovalis (anchylosis of the
footplate of the stapes) (Figs. 126 and 127), or through union of its crura
with the inferior wall of the niche of the fenestra ovalis''*' (anchylosis of the
crura of the stapes) (Fig. 124).

Often I have found the crura of the stapes adherent to the anterior or
posterior wall of the niche (Fig. 125), and more rarely (especially in con-
genital deafness) adhesion of the crura and head of the stapes with the
upper wall of the niche. The anchylosis of the stapes is undoubtedly

* Compare A. Politzer's paper on Histological Changes in the Fenestrse Ovali and
Rocnnda. International Congress, Bmssels, 1888.

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280 THE CATABRHAL ADHESIVE PROCESSES IN THE MIDDLE EAR.

favoured by congenital narrowing of the niche of the fenestra ovalisi and
by the presence of those thread and band-like filaments which one often
finds in the niche of the fenestra ovalis in large numbers as residuxun of
the foetal life, surrounding the crurse of the stapes as a thick network
(Fig. 122). Even when these filaments and bridges of mucous membrane
appear to be absent, one finds by closer examination separate bridges of
mucous membrane which connect the crurse of the stapes with the wall of
the niche (Fig. 128). The more closely the contact of the crurse and wall of
the niche normally, the easier will inflammation produce adhesion of the
surfaces (Politzer, Gradenigo).*^ Within a short time I have dissected three
cases of deafness in which the stapes was fastened to the pelvis ovalis by
the growth of a bony tuberosity.
Anchylosis of the footplate of the stapes with the circumference of the

Fio. 126.— Horizontal SEcriox through the Stapedio- vestibular Articula-
tion IN A Man with Progressive Deafness of a High Degree.
St, Plate of the stapes ; «, Crura of the stapes ; c, Cartilaginous ring of the plate of

the stapes, infiltrated with calcareous molecules ; r, Edge of the fenestra ovalis ;

0, Calcareous infiltrated ring of the stapes ; wi, Sclerosed connective tissue between

the crura of the stapes and niche of the fenestra ovalis. (After a preparation in

my collection.)

fenestra ovaHs is caused either by calcification and ossification of the liga-
mentous ring of the stapes (Fig. 12i6), by a growth of cartilage from the cir-
cumference of the fenestra ovaHs (Wendt), or by deposit of new-formed
osseous substance upon the inner surface of the footplate, and in the neigh-
bourhood of the fenestra ovaHs. Corresponding with the tendinous ring we
find in the latter case, on the labyrinthine side of the fenestra ovaUs, a con-
cave osseous deposit, which slopes down towards the middle of the footplate
of the stapes. There may also be, as I first observed, a complete bony union
of the footplate of the stapes with the wall of the fenestra ovalis (Fig. 127).
The edges of such synostoses are indistinguishable in some cases (Eatz), and
in others are marked by a dark line.

Not less important are the pathological changes in the fenestra rotunda.
One abo finds here, often in normal cases, separate threads or a fibrous network
* Congr^s Otologique. Bruzelles, 1888.

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ANCHYLOSIS OF THE STAPES*

281

stretched across the niche which leads to the fenestra rotunda. These are
in connection with the membrane of the fenestra rotmida, and form the
fomidation for hypertrophic thickening of the mucous membrane covering it.
I have found most frequently in my examinations (I, c) the niche of the
fenestra rotunda filled with a mass of connective tissue, the membrane
thickened (Fig. 128), covered with a villous growth, and the niche greatly
narrowed or completely closed. Calcification of the fenestra rotunda was
observed in a few cases by Toynbee and v. Trdltsch.

Besides the changes in the stapedio-vestibular connection in adhesive pro-
cesses in the middle ear, one occasionally finds changes in the other articula-
tions of the ossicula. Of these may be mentioned : thickening of the
mucous membrane covering the malleo-incudal articulation or anchylosis of

Fio. 127.— Anchylosis of the Plate of the Stapes with the Fenestra Ovalis,
Microscopical Section through the Stapedio-vestibular Connection.

8tf Head of the stapes ; 6, Base of the stapes ; p. Promontory ; a, Spurious adhesion
of the border of the stapes with the fenestra ovalis ; k^ Adhesion of the anterior
border, the edge being still noticeable by the dark line, (^ht ear.) (After a
preparation in my collection.)

it (Toynbee, Zaufal, v. Troltsch), by which, as I proved histologically, the
cartilaginous articular surfaces incrusted with calcareous material are adherent
to the meniscus and to each other. Anchylosis of the articulation between
the stapes and incus was found by Toynbee only twice among 1,149 dissec-
tions.

The pathological alterations in the Eustachian tube are generally dependent
on the extent of the inflammatory process in the middle ear. In the diffused
forms, especially in those connected with chronic naso-pharyngeal affections,
sometimes a moderate, sometimes a great narrowing of the tube takes place.
Kirschner found in one case a formation of diverticuli on the floor of the
canal of the tube. By my examination I have several times found the

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282 THE CATABBHAIi ADHESIVE PBOCESBES IN THE MIDDLE EAR.

mucous membrane covered with several layers of cylindrical or laminated epi-
thelium which were infiltrated with fat globules, the glandular layer was hyper-
trophied in some cases (often through retention of secretion, Moos), in others
atrophied, once completely lacking. The mucous membrane is covered with
excrescences, papiUary, or smooth and atrophic, the cartilage infiltrated with fat
globules and pigment, and sometimes atrophic. In circumscribed interstitial
inflammations, however, the Eustachian mucous membrane is, as a rule,
normal, and the tube is therefore completely permeable. This holds good,
however, only in the majority of cases ; for, just as in cases where there have
been adhesive processes, after catarrh has passed away, there may remain a
freely permeable and even very wide Eustachian canal (v. Troltsch), so we
often find a pronounced stricture of the Eustachian tube in the circumscribed
forms of inflammation in the tympanic cavity.

Fio. 128.— Anterior Section through the Niche of the Fenestra Rotunda
IN A Woman aged 80 Years. Thickening and Hypertrophy of the
Mucous Membrane covering the Fenestra Rotunda following Middle
Ear Catarrh.

pr, Promontory ; r, r', Membrana fenestr. rotundsB ; e, Hypertrophic muooos mem.
covering the membr. fenestr. rotund. (After a preparation in my collection.)

The alterations in the muscles of the Eustachian tube are of consequence
in so far as by their decreased power of action the necessary ventilation of
the middle ear is interrupted. Besides the paralytic conditions to which we
wiU revert later on, we must especially mention fatty degeneration of the
muscular apparatus of the pharyngeal portion of the tube met with in cases
of long-standing inflammation of the naso-pharynx, also atrophy and cica-
tricial contraction of the muscles as consequences of ulceration (syphilis,
scrofula) of the naso-pharyngeal mucous membrane, restricted action of the
muscles in defects of the palate, cleft palate, and adhesion of the vela palati
to the walls of the pharynx.

The changes in the intra-tympanic muscles occurring in chronic adhesive
affections are to be considered as secondary processes. They consist of fatty
degeneration, atrophy, and cicatricial or colloid degeneration (Moos), deve-

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ETIOLOGY AND OCCUBBBNCE. 283

loped partly by inflammation of the neighbouring mucous membrane of the
middle ear, partly by the arrested action of the muscles, in consequence of
anchylosis of the ossicula. Very often in long-continued anchylosis of the
stapes I could find no change in the intrinsic muscles of the ear.

Etiology and Occurrence. — The most frequent causes of the
adhesive processes are the following :

(1) Frequent recurrence of secretive catarrh; (2) chronic naso-
pharyngeal catarrh and oz«Bna, by which recovery from the existing
middle-ear a£fection is retarded ; (3) paresis and paralysis of the
muscles of the palate and tube, which, with facial paralysis, some-
times occur as the sequelsdiof diphtheria; also fatty degeneration
and atrophy of the same, by which the necessary ventilation of the
middle ear is prevented; (4) general diseases, especially scrofula,
tuberculosis, syphilis, Bright's disease, chronic rheumatism, anaemia
and marasmus ; (5) pregnancy and the puerperal state ; (6) here-
ditary predisposition, (according to Moos in 37 per cent, and
according to Bezold in 43 per cent, of the cases) ; (7) external sources
of injury, especially such as, in consequence of the occupation of
the patient, continually operate upon the organism, living in a damp
house, excessive applications of hydropathy (v. Troltsch), and pro-
tracted 'sea-bathing during the existence of middle-ear catarrh ;
(8) the immoderate use of alcoholic liquors and excessive smoking
(Triquet, Ladreit de Lacharri^re), by which the development of
permanent new-formation of tissue in the mucous membrane of
the middle ear is favoured in chronic catarrh.

The adhesive processes in the middle ear occur most frequently
in middle-aged and old people, less frequently in children and young
persons, who are most subject to the exudative forms of catarrh.
The development of adhesive processes in the middle ear, which
have arisen during childhood in consequence of catarrhs, can easily
be traced to disturbance of nutrition, especially scrofula, ansBmia,
or to hereditary tendency. In a not inconsiderable number of cases,
the adhesive processes in the middle-aged are caused by catarrhs
which date from childhood.

Adhesive inflammation of the middle ear usually afiects both ears,,
being seldom confined to one only. The disease generally presents
the same character in both ears ; often, however, the phenomena of
secretive catarrh appear in one ear while in the other there exists
an interstitial adhesive inflammation of the mucous membrane (dry
middle-ear catarrh). But the combination of the last-named form
of disease in the one ear, with purulent perforating inflammation
in the other, is not uncommon.

Condition of the Membrana Tympani. — The colour and trans-

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284 THE GATARBHAL ADHESIVE PROCESSES IN THE MIDDLE EAB.

parency of the membrane are most frequently affected in adhesive
processes of the middle ear, the membrane being partially or wholly
rendered dull and non-transparent.

In the former case, the parts affected appear as definite or ill-
defined opacities, of a tendinous-gray colour, striated or spotted,
and between these the normal or less obscured portions of the
membrana tympani appear as dark spots, apparently depressed.
These opacities vary greatly in size and shape. Among the more
frequent shapes is the semilunar, situated behind the hammer, with
the convexity turned towards the periphery, and of the colour of
milk-white glass or tendinous-gray, a form which, unlike the chalky

o^B

- Semilunab Fio. 131. — Horseshoe
Deposit in Chalk y Deposit in the
Membrana Tthpani
OF A Woman 30 Years
Old.
Duration of the ear diaeaae
10 years. Tinnitus sel-
dom. Acoumeter = 30
cm. Speech ^ 3 m.

Fig. 130.
Chalky

FRONT OF the HaNDLK

OF THE Malleus in a
Man 38 Years Old.

Fig. 129.-— Semilunar Opa-
city BEHIND THE HANDLE

OF THE Malleus in a
Woman 38 Years Old.
Duration of the ear disease 6
years ; greatly aggravated
during the last 3. Acou-
meter = 1cm. Speech — 10
cm. Perception through
the bones of the skull un-
altered. Tuning-fork on
vertex heard best in the
affected right ear.

deposits, is not sharply defined, but merges into the transparent
parts of the membrane (Fig. 129), its margins gradually becoming
less distinct. Peripheral, whitish-gray and circular opacities are
frequently found, comparable to the arcus senilis of the cornea, and
due to the thickening of the mucous membrane of the periphery of
the membrana tympani and opacity of the annulus tendinosus.

A more rare condition found in this middle-ear process is the
calcareous deposits on the membrana tympani as chalky white,
sharply defined spots, situated between the handle of the malleus
and the periphery. They are found most frequently in front of the
handle of the malleus, more rarely behind it, in the shape of a
crescent, directed with its convexity towards the periphery (Fig. 130).
Sometimes a chalky spot is visible both in front of and behind the

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CONDITION OP THE HEMBBANA TTMPANl. 285

handle, or the inferior extremity of the handle is surrounded by a
horseshoe-shaped deposit (Kg. 131).

Not less frequently the membrana tympani is rendered non-
transparent in its whole extent. In this case it appears some-
times irregularly spotted gray, sometimes of a homogeneous bluish-
white colour, like a glass surface that has been breathed upon,
sometimes as a sodden whitish-gray membrane, almost perfectly
opaque, the aspect of which might be compared to a lustrous milk-
white glass plate, upon which the posterior fold of the membrana
tympani is plainly marked. In great thickening of the membrana
tympani, and with its extensive union with the inner wall of the
tympanum, the membrane presents the appearance of a yellowish
disc of parchment. In cases in which the growth of connective
tissue producing adherences in the cavum tympani is h3rper8Bmic
or pigmented the membrana tympani has a reddish-gray or bluish-
gray appearance.

The appearance of the handle of the malleus is often also per-
ceptibly altered. Its margins often seem ill-defined, the handle
itself apparently widened, and the umbilical opacity increased.

The cone of light either shows the normal, triangular shape, or
is irregular, indistinct, much narrowed or shortened by retraction
of the membrana tympani (seldom lengthened).

The curvature of the membrana tympani in the chronic adhesive
processes suffers striking alterations.

To a greater or less extent the membrane appears drawn inwards,
thickened, or atrophied and wrinkled ; the handle of the malleus
appears foreshortened, displaced inwards, backwards, and upwards,
and partly covered; the short process and the fold of the mem-
brane extending backwards (Fi

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Full text of "Politzer's Textbook of diseases of the ear and adjacent organs : for students and practitioners"

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